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^itirarp 


MINOR  MEDICINE 

A  Treatise   on   the   Nature  and 
Treatment  of  Common  Ailments 


By 

WALTER    ESSEX    WYNTER 

M  D.,  B.S.  (Lond.),  F.R.C.P.,  F.R.C.S. 

Physician  to  the  Middlesex  Hospital  and  Lecturer  on  Medicine 
in  the  Medical  School.  Late  Examiner  in  Medicine  to  the 
Royal  College  of  Physicians ;  Lecturer  in  Pharmacology  and 
Therapeutics  and  Examiner  in  Pharmacy  to  the  Royal 
College  of  Physicians 


SECOND  EDITION.     REVISED  AND  ENLARGED 


NEW  YORK  AND  LONDON 
D.   APPLETON   AND   COMPANY 

MCMXVI 


1^ 


Published 
Reprinted . 
Reprinted . 
Reprinted . 
Reprinted . 
Second  Edition 
Reprinted , 


Sept.  1907 
MarchldOS 

July  1908 

Sept.  1909 

Feb.  1910 

Nov.  1913 

Jan.  1916 


Copyright,  1907,  1908,  1909,  1910,  1913,  1916 
All  rights  reserved 


MY  HOUSE  PHYSICIANS 

WHOSE   LNTEREST   AND    COLLABORATTON 

HAVE    ENCOURAGED    THE   DEVELOPMENT   AND 

ARRANGEMENT   OP   THE   MATTER   SET 

FORTH   IN   THE   FOLLOWING 

PAGES 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/minormedicinetreOOwynt 


PEEPACE 

For  who  hath  despised  the  day  of  small  things. — Zechariah  iv.  10. 

The  change  in  the  system  of  medical  education  some 
thirty  years  ago,  whereby  the  custom  of  commencing  as 
pupil  to  a  medical  man  in  general  practice  was  abandoned 
in  favour  of  proceeding  straight  from  the  course  of  general 
education  to  a  medical  school  or  university,  has  involved 
certain  deficiencies  in  the  knowledge  of  those  so  trained. 
Since  the  subjects  of  what  might  be  regarded  as  trifling 
disorders  either  do  not  present  themselves  at  a  hospital 
or  are  intercepted  in  the  casualty  department  in  order 
to  spare  the  time  and  energy  of  the  visiting  staff,  the 
present-day  student  has  little  or  no  opportunity  of 
familiarising  himself  with  those  slighter  maladies  which 
are  likely  to  be  among  the  first  encountered  when  he 
commences  practice.  This  is  no  doubt  accentuated  by  the 
natural  tendency  of  students  to  concentrate  their  attention 
on  those  organic  diseases  which  are  mostly  inquired  about 
at  examinations  and  to  interest  themselves  in  rare  diseases, 
complex  or  extensive  operations,  and  questions  of  higher 
research — matters  of  the  utmost  importance  in  regard  to 
the  progress  of  medicine,  but  with  which  those  who  are 
occupied  in  family  practice,  and  who  constitute  perhaps 
ninety  per  cent,  of  the  profession,  are  comparatively  rarely 
directly  concerned,  at  all  events  in  early  years.     It  is 

vii 


viii  Preface 

in  the  hope  of  conveying  some  information,  and  of 
arousing  interest  in  the  sphere  of  Minor  Medicine,  that  the 
present  small  volume  has  been  written. 

My  grateful  acknowledgments  are  due  to  Mr.  G.  S. 
Hughes  for  help  and  suggestions  in  revising  the  proofs 
and  preparing  the  index. 

W.  ESSEX  WYNTER. 

27,  WiMPOLE  Steeet, 

Cavendish  Squaee,  W. 


CONTENTS 


PAGE 

INTRODUCTION xi 


CHAPTER   I 
THE   DIGESTIVE    SYSTEM  ...  «  ,  ,  1 

CHAPTER  II 

DISEASES   OF  THE   SKIN  .......        48 

CHAPTER  III 
THE   RESPIRATORY   SYSTEM        ....••         88 

CHAPTER  IV 

NERVOUS   SYSTEM i  •      HI 

CHAPTER  V 

THE   CIRCULATORY   SYSTEM       ,  .  ,  «  •  .148 

CHAPTER  VI 

THE   MUSCULAR  SYSTEM  .  .  ,  .  ,  ,  .164 

iz 


X  Contents 

PAGE 

CHAPTER  VII 
SPECIAL   SUBJECTS  . 174 


CHAPTER  VIII 
MAINTENANCE   OF   INDIVIDUAL   HEALTH    .  .  .  ,199 

CHAPTER  IX 

DIET ,  .      215 

FORMULA ,      250 

INDEX 268 


INTRODUCTION 

In  attempting  to  deal  with  such  matters  as  the  minor 
derangements  of  health,  the  difficulty  at  once  presents 
itself  of  steering  a  middle  course  between  indispositions 
too  trifling  or  familiar  to  deserve  mention  and  those 
which  already  receive  ample  attention  in  more  serious 
books  on  medicine,  and  it  is  probable  that  transgressions 
in  both  these  directions  will  meet  the  critical  eye. 

More  formidable  still  is  the  danger  of  including  among 
trifling  ailments  phenomena,  which,  though  apparently  of 
sHght  importance,  may  belong  to  really  serious  disease, 
but  it  would  be  practically  impossible  to  define  these 
differences  in  all  cases  without  expanding  these  pages 
into  a  substantial  treatise  on  medicine. 

Apart  from  the  risks,  medical  and  surgical,  which 
are  associated  with  occupation,  and  possibly  even  more 
with  lack  of  it,  there  are  inherent  or  acquired  tendencies 
which  assert  themselves  at  different  periods  of  life,  and 
underlie  apparently  trifling  ailments.  Thus,  in  the  first 
twenty-five  years  tuberculosis  is  likely  to  prevail,  in  the 
second  similar  period,  syphilis,  and  in  the  third,  gout  or 
cancer,  and  it  is  well  to  keep  these  probabilities  in  mipd 
in  dealmg  even  with  superficial  indications. 

On  this  account  minor  disorders  must  be  considered 
in  relation  to  the  state  of  the  general  health  and  in  view 
of  probable  underlying  diathesis. 

A  blister  resulting  from  friction  or  heat  is  not  a 
serious  matter,  though  such  a  manifestation  appearing 
spontaneously,  or  in  the  subject  of  glycosuria  or  renal 


xii  Introduction 

disease,  might  reasonably  give  rise  to  grave  anxiety. 
Vomiting  after  injudicious  feeding  only  brings  relief, 
while  spontaneous  vomiting  may  indicate  serious  brain 
disease  or  other  vital  disorder. 

Symptoms  which  represent  response  to  a  known  and 
trifling  cause  of  disturbance  may  be  hghtly  regarded, 
whereas  such  as  emanate  from  an  internal  or  constitu- 
tional state  are  of  much  more  serious  augury.  It  is 
"  that  which  proceedeth  from  within  "  which  is  of  the 
greater  moment. 

This  general  discrimination  is  not  always  easy,  but 
it  may  be  concluded  that  persistence  or  increase  in  any 
local  phenomenon  points  to  some  underlying  cause,  and 
the  occurrence  of  what  is  termed  bodily  illness  goes  far 
to  confirm  the  suspicion  of  actual  constitutional  disease. 
No  better  illustration  of  this  could  be  found  than  an 
outbreak  of  warts,  which  in  a  young  robust  individual 
is  a  matter  of  small  concern,  but  in  an  elderly  person 
exhibiting  cachexia  and  pigmentation  may  indicate  that 
rare  form  of  maUgnant  disease,  Acanthosis  nigricans. 

It  must  be  insisted,  therefore,  that  none  wUl  assume 
the  responsibility  of  dealing  even  with  minor  maladies, 
without  that  general  knowledge  of  medicine  and  mental 
caution  which  guards  against  the  confusion  of  great  things 
with  small. 

There  are  few  greater  tragedies  in  medical  experience 
than  those  involved  in  the  recognition  of  deadly  disease 
in  what  a  patient  has  regarded  as  a  trifling  ailment. 
Every  now  and  then  in  every  doctor's  experience  such 
a  one  wiU  hghtly  ask  advice  about  what  appears  to  him 
a  mere  pimple,  but  which  skilled  examination  proves  to 
be  the  outpost  of  malignant  disease,  involving  a  mutilating 
operation  and  ultimate  threatening  of  life  itself.  So, 
also,  the  persistence  of  such  a  common  symptom  as 
constipation  or  mere  languor  may  lead  to  the  recognition 
of  Diabetes  or  Bright's  disease,  which  proves  fatal  in  a 


Introduction  xiii 

few  months.  How  many  are  the  consumptives  who  feel 
and  say  that  if  only  they  could  get  rid  of  their  cough  they 
would  be  quite  well.  Medical  practice  is  full  of  such 
incidents,  saddening  and  indeed  tragic  in  the  anticlimax 
that  ensues. 

These  instances,  however,  are  the  rare  exceptions, 
which,  while  they  impose  the  need  for  wariness  in  dealing 
with  any  marked  manifestation,  especially  such  as  persist 
or  are  associated  with  general  impairment  of  health, 
yet  leave  ample  scope  in  the  vast  majority  for  the  rehef 
of  discomfort  or  actual  suffering  by  simple  means. 

Before  proceeding  to  a  detailed  consideration  of 
departures  from  the  standard  of  health,  it  may  be  well 
to  survey  some  points  in  the  development,  growth, 
maintenance,  and  decay  of  the  human  organism,  which 
may  be  regarded  as  representing  natural  phases  in  the 
course  of  Kfe. 

The  average  weight  of  the  infant  at  birth  is  seven  and 
a  half  pounds  for  males  and  seven  pounds  for  females. 
There  is  usually  a  loss  of  one  pound  during  the  first  three 
days  which  is  made  up  in  the  next  seven,  so  that  by  the 
tenth  day  the  weight  is  the  same  as  on  the  first.  Con- 
tinued loss  indicates  malnutrition,  maldevelopment,  or 
disease.  At  the  end  of  the  first  year  the  weight  should 
be  three  times  that  at  birth.  An  average  gain  of  four 
ounces  per  week  for  the  first  six  months  is  usual.  During 
the  second  year  the  gain  is  six  pounds,  and  during  the 
third  four  and  a  half.  Four  pounds  per  annum  should 
be  added  in  the  fourth,  fifth,  sixth,  seventh  and  eighth 
years,  and  six  pounds  per  annum  during  the  ninth,  tenth 
and  eleventh.  Increase  is  more  marked  in  the  autumn, 
and  girls  develop  faster  between  the  ages  of  eleven  and 
thirteen,  while  the  principal  period  of  growth  for  boys  is 
from  fifteen  onwards. 

The  height  at  birth  is  20" 61  inches  for  boys,  and  20*47 
for  girls.     Eight  inches  should  be  added  in  the  first  year. 


xiv  Introduction 

three  and  a  half  in  the  second,  and  two  or  three  annually 
till  the  eleventh.  At  twelve  and  thirteen  girls  exceed 
boys,  though  these  from  fifteen  onwards  more  than  make 
up  the  deficiency. 

Rickets  in  early  life  tends  to  limitation  of  the  ultimate 
stature.  The  importance  of  these  weights  and  measures 
lies  in  the  fact  that  in  health  steady  progress  in  height 
and  weight  is  the  rule,  and  any  check  is  a  sure  indication 
of  disease  or  malnutrition. 

The  circumference  of  the  head  is  13' 9  in  the  male 
and  13'5  in  the  female,  increasing  four  inches  during  the 
firsl  year,  one  inch  in  the  second,  and  a  further  inch  and 
a  half  betweei:.  two  and  five. 

The  sutures  remain  open  till  the  sixth  month  and 
movable  to  the  ninth.  The  posterior  fontanelle  closes 
at  the  second  month,  the  anterior  remaining  incom- 
pletely closed  till  the  eighteenth.  Earlier  closure  in- 
dicates arrested  growth  of  the  brain.  Rickets  delays 
closure  even  to  the  end  of  the  third  year,  and  cretinism 
till  the  eighth.  Compression  deformity  disappears  at 
the  end  of  the  first  month,  though  the  head  remains 
mouldable  till  the  end  of  the  first  year. 

The  antero-posterior  and  transverse  diameters  of  the 
chest  are  equal  in  the  new  born  infant,  and  up  to  the 
third  year  the  transverse  diameter  of  the  head,  chest 
and  abdomen  are  equal.  Subsequently  the  chest  expands 
more  than  the  other  two. 

At  the  fourth  month  voluntary  movements  occur, 
especially  attempts  at  grasping,  and  the  head  can  be 
held  erect.  About  the  seventh  month  the  infant  can 
sit  up,  and  may  stand  by  the  ninth,  commencmg  to  walk 
when  a  year  old,  and  going  without  support  at  fifteen 
months. 

The  newly  born  avoid  light,  the  pupils  contract  and 
the  lids  close.  The  extrinsic  muscles  of  the  eye  are  not 
co-ordinated  till  the  third  month.     The  cornea  is  only 


Introduction  xv 

slightly  sensitive,  so  that  care  must  be  exercised  in  washing, 
and  the  eye  does  not  close  in  the  first  weeks  of  life  when 
an  object  is  approximated.  In  the  first  few  weeks  also 
the  iris  in  all  babies  is  of  a  uniform  slatey  blue.  Though 
the  eyes  may  follow  a  moving  object,  there  is  no  definite 
recognition  till  the  sixth  month,  and  no  tears  appear 
duriiig  the  first  eight  or  ten  weeks. 

Hearing  is  not  developed  for  twenty-four  hours  after 
birth,  and  in  some  cases  not  for  several  days.  It  is  very 
acute  for  the  first  few  months,  the  child  starting  at  sounds 
and  sometimes  falling  into  convulsions  at  sudden  noise. 
At  two  to  three  months  the  infant  turns  towards  sounds, 
and  within  another  month  apparently  recognises  the 
voice.  Tactile  sensibility  is  present  at  birth,  but  is  not 
acute  except  m  the  lips  and  tongue.  After  the  third 
month  this  becomes  general,  though  the  mouth  remains 
very  sensitive  to  slight  changes  of  temperature,  so  that 
special  care  is  needed  in  administering  food. 

Speech  begins  at  the  end  of  the  first  year,  girls  as  a 
rule  advancing  quicker  than  boys.  The  teeth  usually 
begin  to  appear  at  the  sixth  month,  and  the  first  set 
should  be  complete  by  the  end  of  the  second  year,  but 
in  some  quite  healthy  children  none  appear  till  the  tenth 
month.  Syphilis  tends  to  advance  and  rickets  or  creti- 
nism to  delay  dentition.  During  the  first  six  months 
there  is  only  sufficient  secretion  from  the  mucous  mem- 
brane to  keep  the  mouth  moist,  the  salivary  glands  and^ 
presumably  the  pancreas,  are  not  functional,  so  that 
starchy  food  cannot  be  digested.  With  the  appearance 
of  the  teeth,  however,  salivation  is  established,  and  thence 
forward  the  addition  of  starches  to  the  diet  is  permissible 
and  desirable,  albeit  the  eruption  of  the  teeth  may  render 
a  return  to  the  simplest  food  temporarily  necessary. 

Though  the  constitutional  effects  of  dentition  appear 
to  have  been  much  exaggerated  and  such  remedies  as 
gum-lancing  have  now  become  practically  obsolete,  there 


xvi  Introduction 

can  be  no  doubt  that  excitation  of  the  nervous  system 
with  irritabihty  and  fractiousness  do  accompany  the 
appearance  of  the  milk  teeth,  attended  in  some  cases 
with  stomatitis  and  skin  eruptions,  as  well  as  disturbance 
of  the  digestive  system  manifested  by  vomiting  and 
diarrhoea,  and  more  rarely  extension  of  catarrhal  changes 
to  the  respiratory  tract.  It  is  advisable,  therefore,  that 
additions  to  the  dietary  at  this  time  should  be  made  with 
caution  and  with  due  consideration  for  the  recurring 
disabilities  of  this  period. 

Another  feature  of  infancy  is  the  delay  in  development 
and  functional  activity  of  the  sudoriferous  glands,  render- 
ing infants  intolerant  of  external  heat  and  liable  to  undue 
rise  of  the  body  temperature  with  comparatively  shght 
internal  disturbances.  This  absence  of  sweating  affords 
a  substantial  reason  for  frequent  bathing. 

At  the  end  of  the  first  year  the  weight  should  be 
nearly  three  times  that  at  birth,  and  thenceforward  the 
yearly  increase  should  be  from  four  to  six  pounds  up  to 
the  age  of  eleven.  About  this  time  girls  develop  at  a  greater 
rate  than  boys,  and  from  twelve  to  fourteen  commonly 
exceed  them  in  weight  and  height.  Thereafter,  from 
fourteen  onwards,  the  male  develops  at  a  greater  rate, 
and  the  female  at  a  less,  so  that  by  fifteen  the  temporary 
lead  of  the  girl  is  extinguished. 

It  is  interesting  to  note  in  this  connection  that  the 
size  and  weight  of  the  heart  maintains  a  relative  pro- 
portion to  that  of  the  body,  weighing  one  ounce  at  birth 
and  adding  half  an  ounce  each  year  up  to  the  age  of 
twelve,  when  it  weighs  about  seven  ounces. 

Owing  to  the  relative  narrowness  of  the  thorax  in 
childhood  the  apex  beat  usually  extends  to  the  nipple 
line  as  a  normal  condition,  and  in  adults  who  retain  this 
infantile  form  of  cylindrical  chest  the  same  relative 
position  in  regard  to  the  nipple  continues  throughout 
life.     The  years  from  twelve  to  sixteen  in  girls  and  from 


Introduction  xvii 

fifteen  to  nineteen  in  boys  are  those  of  most  rapid  growth 
and  expansion,  and  it  is  at  this  time  that  the  heart 
increases  most  rapidly,  adding  an  ounce  per  year  to  its 
weight.  The  apex  beat  assumes  its  adult  position  within 
the  nipple  line,  and  any  arrest  of  development  following 
on  inflammatory  infiltration  of  valves  becomes  in- 
creasingly apparent.  This  is  especially  noticeable  in 
regard  to  mitral  stenosis,  which,  though  occasionally 
indicated  by  an  accentuated  first  sound  associated  with 
a  systolic  murmur  in  childhood,  never  presents  a  definite 
presystohc  murmur  till  about  the  twelfth  year.  From 
this  age  onwards  such  a  murmur  is  increasingly  prevalent, 
especially  in  girls,  though  signs  of  faihng  compensation 
are  rare  before  twenty.  Indeed,  reserve  power  and 
compensation  are  so  good  during  the  period  of  growth, 
that  mechanical  failure  and  dropsy  at  this  period  of  Ufe 
must,  with  confidence,  be  attributed  to  adherent  peri- 
cardium, which  is  found  in  nearly  all  fatal  cases.  A 
pronounced  constriction  of  the  mitral  valve  is  not  un- 
commonly associated  with  dwarfing  in  stature  and  much 
delayed  development,  and  when  combined  with  cyanosis 
could  scarcely  fail  to  attract  notice. 

The  period  of  second  dentition  commencing  with  the 
eruption  of  the  first  permanent  molar  at  the  age  of  six 
is  often  associated  with  impaired  health,  both  in  boy& 
and  girls.  There  is  an  interregnum  while  the  decay  of 
the  first  set  of  teeth  tardily  replaced  by  the  second  leaves 
the  individual  in  a  varying  degree  edentulous,  and  exposes 
him  to  the  discomforts  and  dangers  of  local  inflammation 
and  infection  to  an  extent  that  has  only  recently  been 
taken  seriously  into  account. 

As  this  occurs  at  a  time  when  the  demand  for  nutrition^ 
and  especially  animal  food,  is  increasing,  special  attention, 
both  as  regards  dietary  and  the  state  of  the  mouth,  is 
needed. 

It  is  doubtful  whether  children  ever  achieve  proper 


xviii  Introduction 

mastication  with  the  milk  teeth,  and  they  are  certainly- 
further  handicapped  in  the  interregnum  between  them 
and  the  permanent  set  up  to  the  age  of  thirteen.  Fortu- 
nately about  this  time  of  life  they  are  under  the  eye  of 
their  parents  or  in  preparatory  schools,  where  these 
defects  can  in  some  measure  be  counteracted. 

The  first  and  second  seven-year  periods  of  growth  are 
also  those  in  which  the  exanthemata  mostly  occur,  and 
these  should  be  foremost  in  the  mind  when  febrile  dis- 
turbances manifest  themselves,  both  for  the  welfare  of 
the  individual  and  the  added  responsibility  of  guarding 
others  from  infection.  It  has  been  sometimes  suggested 
that  it  is  well  or  at  least  convenient  to  be  through  with 
these  complaints  in  a  family  of  children,  and  certainly 
the  individual  who  has  safely  surmounted  the  various 
infective  diseases  has  an  enhanced  value  in  freedom  from 
inconvenient  checks  during  adolescence  ;  but  when  it  is 
sufficiently  realised  that  the  outcome  of  any  form  of 
infectious  disease  cannot  be  confidently  foretold,  involving, 
as  it  does,  a  certain,  if  small,  mortality  and  the  possibility 
of  permanent  maiming  :  this  consideration  should  give 
pause  to  the  practice  of  purposely  exposing  healthy 
children  to  the  risk  of  infection  and  its  possible  conse- 
quences, and  should  be  seriously  urged  when  such  a 
procedure  is  proposed  by  people  unversed  in  the  course 
of  disease.  Certainly  no  experienced  medical  man  would 
be  a  party  to  running  a  real  risk  for  the  sake  of  con- 
venience. 

Passing  from  the  periods  of  infancy  and  childhood, 
the  individual  enters  upon  adolescence  and  is  free  in 
general  from  health  disturbances  except  for  belated 
exanthemata  to  which  he  may  be  exposed  at  school,  and 
the  accidents  incidental  to  sports  and  pastimes.  One 
exception  to  this,  however,  exists  in  the  occurrence  of 
rheumatism,  which  is  a  disease  especially  prevalent  in 
the  period  of  growth  and  development,  but  is  less  com- 


Introduction  xix 

monly  overlooked  at  this  time  of  life,  since  it  is  almost 
invariably  associated  with  painful  arthritis,  a  feature  of 
the  disease  not  uncommonly  lacking  in  early  childhood. 

The  morbid  tendencies,  however,  of  this  phase  of  life 
have  been  so  exhaustively  treated  of  in  the  publications 
of  school  medical  officers,  that  practically  nothing  remains 
to  be  specially  noticed. 

Girls  at  about  the  age  of  sixteen  sometimes  display  a 
conspicuous  enlargement  of  the  thyroid  gland  unaccom- 
panied by  symptoms,  which  usually  subsides  in  the  course 
of  a  year  or  two  without  treatment. 

Some  temporary  turgescence  may  recur  at  the  men- 
strual periods  giving  a  slight  fullness  to  the  front  of  the 
neck  as  well  as  the  breasts. 

The  more  persistent  enlargement  at  puberty  is 
functional,  and  of  much  the  same  character,  so  need  not 
give  rise  to  anxiety. 

Morbid  disturbances,  especially  such  as  are  associated 
with  the  distribution  of  micro-organisms  in  the  blood- 
stream, are  apt  to  show  themselves  in  those  areas  where 
active  growth  and  development  are  associated  with 
dilatation  of  the  vascular  channels,  such  as  the  epiphyses 
of  bones  and  the  establishment  of  functional  activity  in 
the  organs  of  generation,  leading  to  local  disease  in  the 
subjects  of  tubercle  at  this  period,  and  in  others  to 
functional  disturbances. 

It  is  in  the  growing  period  that  the  lymphatic  glands 
are  most  liable  to  infection,  and  hyperplasia  as  evidenced 
by  the  prevalence  of  tonsilitis,  adenoids,  adenitis  of  the 
lymph  glands,  and  susceptibility  of  Peyer's  patches  to 
typhoid  and  other  infections. 

The  period  of  growth  and  development  calls  therefore 
for  a  generous  supply  of  sound  plain  food,  ample  air 
space  both  by  night  and  day,  and  the  avoidance,  as  far 
as  possible,  of  exposure  to  infections  such  as  might  be 
expected  in  crowded  places  and  in  tropical  countries, 


XX  Introduction 

young  people  being  particularly  vulnerable  under  such 
circumstances. 

The  frequency  with  which  pulmonary  tuberculosis 
asserts  itself  in  adolescents  and  young  adults  at  the 
commencement  of  the  working  period  of  life  goes  far  to 
prove  this,  especially  when  contrasted  with  the  relative 
immunity  of  the  immediately  preceding  years  of  school 
life. 

As  the  skeletal  system  is  not  completely  consolidated 
till  the  twenty-fifth  year,  this  should  be  regarded  as  the 
commencement  of  adult  hfe,  and  successive  periods  of 
twenty-five  years  might  mark  the  young,  middle-aged, 
and  old,  if  human  hfe  were  conducted  on  ideal  fines. 

As  things  actually  are,  for  most  people  it  would  be 
more  in  accord  with  experience  to  account  them  immature 
till  twenty,  young  till  forty,  middle-aged  till  sixty,  and 
thenceforward  old. 

According  to  this  computation  only  a  minority  attain 
old  age,  though  many  acquire  the  characteristics  pre- 
maturely. 

While  growth  and  development  are  proceeding,  in 
spite  of  persistent  appetite  and  ample  dietary,  the  in- 
dividual tends  to  be  spare,  but  with  completion  of  these 
there  is  a  noticeable  increase  of  bulk,  due  to  fat  and 
muscle,  and  the  youth  is  said  to  "fill  out."  This  stage 
usually  coincides  with  a  more  settled  and  physically  less 
strenuous  mode  of  life,  often  with  marriage. 

Most  people  appear  to  arrive  at  a  state  when  for  many 
years  they  change  very  little  in  appearance  or  bulk, 
and  any  decided  variation  attracts  notice. 

The  demands  of  growth  and  development  are  such 
that  much  food  is  required,  but  assimilation  and  functional 
activity  are  so  great  that  httle  remains  over  for  storage, 
and  starvation  tells  very  much  more  quickly  on  children 
than  adults.  When  the  growing  period  is  completed 
and  the   habit   of  hberal  feeding   is   continued,   unless 


Introduction  xxi 

balanced  by  strenuous  work,  flesh  is  put  on,  at  first 
uniformly,  but  with  middle  age,  when  physical  activity 
diminishes  and  a  steady  routine  takes  its  place,  local 
accumulation  occurs  and  the  individual  becomes  stout. 

This  may  in  time  react  on  activity,  since  more  effort 
is  required  to  support  and  move  a  heavy  body,  and 
disinclination  for  exertion  results,  with  danger  of  in- 
creasing obesity.  The  accumulated  fat  represents  only 
the  inconvenience  ;  the  danger  to  health  and  long  life 
resides  in  the  nitrogenous  suboxidised  constituents  of 
the  food,  which  overwork  and  damage  the  internal 
organs,  particularly  the  heart  and  kidneys. 

Throughout  the  insect  world  it  is  noticeable  that  the 
larval  stage  is  characterised  by  extraordinary  voracity, 
which  contributes  to  the  size  and  vigour  of  the  perfect 
insect,  but  the  mature  creature  eats  little,  and  in  some 
cases  not  at  all. 

Human  beings  would  do  well  to  follow  this  example 
and  diminish  the  amount  of  nutriment  when  the  body 
has  attained  its  full  development.  Hard  and  continuous 
work,  whether  with  brain  or  muscle,  necessarily  requires 
sufficient  food  to  repair  waste  and  to  supply  a  reserve 
during  the  period  of  activity,  but  this  does  not  lead  to 
flesh-forming. 

It  is  remarkable  that  lame  people  usually  have  enor- 
mous appetites  but  do  not  get  fat,  the  enhanced  muscular 
effort  necessitated  by  mechanical  disadvantage  counter- 
balancing and  calling  for  this  exceptional  supply.  They 
may  be  compared  with  badly  designed  engines,  in  which 
the  work  co-efficient  is  low  and  only  maintained  by  an 
extravagant  combustion  of  fuel. 

Apart  from  the  question  of  defective  digestion  and 
assimilation  or  the  presence  of  wasting  disease,  it  may 
be  concluded  that  excess  of  food  with  deficient  output  of 
energy  involves  the  accumulation  of  fat,  and  a  deficiency 
of   nutriment   with   disproportionate   output   of   energy 


xxii  Introduction 

leads  to  attenuation,  hence  the  efficacy  of  the  rest  cure, 
especially  in  thin  people.  Testing  the  body  weight  at 
intervals  is  a  valuable  help  in  controlling  the  balance,  and 
the  maintenance  of  a  steady  weight  within  slight  varia- 
tions dependent  on  changes  in  mode  of  life,  is  a  sure 
indication  of  health. 

The  question  of  balance  between  food  and  activity  is 
of  the  utmost  importance  throughout  life,  and  needs 
special  adjustment  in  the  different  periods.  In  adolescents 
the  only  limit  is  imposed  by  the  capacity  of  the  digestive 
organs  in  volume  and  efficiency,  and  the  only  ill  effect 
of  over-feeding  is  the  disturbance  of  these  organs, 
commonly  remedied  spontaneously  by  facile  emesis  or 
temporary  failure  of  appetite. 

In  adults  excess  of  food  over  the  needs  of  the  body 
maintenance  results  on  the  one  hand  in  accumulation  of 
fat,  and  on  the  other  in  the  surcharge  of  the  blood  and 
tissues  with  an  undue  quantity  of  imperfectly  oxidised 
nitrogenous  products,  while  the  undigested  surplus  under- 
goes unwholesome  fermentation  in  the  digestive  tract ; 
clouding  the  mental  faculties,  disturbing  the  temper, 
over-stimulating  the  generative  organs,  and  overworking 
the  emunctories. 

It  is  highly  probable  that  excess  of  food,  and  especially 
of  animal  food,  over  the  natural  requirements  and  assimila- 
tive capacity  of  the  body  is  the  chief  cause,  not  merely  of 
disorders  of  the  digestive  organs,  but  of  degenerative 
changes  in  the  circulatory  and  renal  system,  particularly 
arterial  sclerosis,  which  accounts  for  the  majority  of 
deaths  in  the  ten  years  before  and  after  sixty,  apart  from 
the  effects  of  syphilis  and  some  other  diatheses  which 
operate  at  an  earlier  age. 

Celsus  advised  an  alternation  between  too  little  and 
too  much  food  with  a  general  tendency  towards  too  little, 
and  there  is  much  to  be  said  for  the  system  of  fasting  on 
recurring  days  and  periods  for  its  beneficial  effects  on  the 


Introduction  xxiii 

community,  just  as  a  day  off  once  a  week  in  the  course 
of  drug  treatment  prevents  cumulative  effects  or  undue 
tolerance. 

Feeding  is  not  altogether  a  question  of  means,  for  some 
who  could  afford  much  are  abstemious,  and  many  who 
can  afford  little  eat  excessively.  Some  chronic  invalids 
attain  great  age,  possibly  owing  in  part  to  the  sparseness 
of  their  diet,  and  centenarians  are  met  with  more  often 
in  the  Union  or  almshouse  than  in  the  mansion  or 
palace,  and  more  frequently  among  those  who  have 
worked  hard  for  a  scanty  living  than  among  those  who 
have  spent  their  lives  in  ease  and  luxury. 

Comparable  with  the  remarkable  changes,  both 
psychical  and  physical,  which  occur  with  the  advent  of 
adolescence  in  women,  are  those  which  attend  involution 
of  the  generative  organs  at  the  menopause  in  middle 
age.  The  physical  variations  attending  the  cessation  of 
menstruation  are  a  tendency  to  increased  bulk  and 
weight,  sometimes  the  appearance  of  hair  on  the  chin  and 
upper  lip  and  a  lowering  of  the  pitch  of  the  voice. 
Changes  in  other  regions  occur,  and  it  is  about  this  time 
that  myxoedema,  erythematous  lupus,  rodent  ulcer, 
rheumatoid  arthritis,  and  other  diseases  chiefly  develop  ; 
indicating  special  morbid  tendencies  and  diminished 
resistance. 

The  most  common  and  noticeable  features,  however, 
of  the  menopause  are  the  psychical  changes,  which,  though 
more  pronoimced  in  some  cases  than  others,  are  never 
altogether  absent.  Every  grade  is  met  with,  from  altera- 
tion of  temper  and  disposition,  or  loss  of  self-control,  to 
marked  eccentricity  and  actual  disturbance  of  mental 
balance,  or  fixed  delusions  requiring  restraint  in  an 
asylum. 

Most  of  the  strange  behaviour  manifested  by  women 
of  what  is  called  "  an  uncertain  age  "  is  attributable  to 
this  cause,  which  may  well  be  described  £is  "  the  roaring 


xxiv  Introduction 

forties,"  Family  quarrels  and  estrangements,  extrava- 
gant beliavioiir  in  public  and  the  adoption  of  strange 
cults  and  views  characterise  the  period  in  question. 

Those  who  have  exhibited  neurotic  tendencies  earlier 
in  life  are  apt  to  display  them  in  an  aggravated  form  at 
this  time,  and  may  present  symptoms,  mostly  referable 
to  the  nervous  system,  which  are  confusing  and  puzzling, 
unless  the  age  and  circumstances  are  taken  into  account. 
Functional  affections  of  all  kinds  occur,  and  conditions 
such  as  acroneurosis,  erythromelalgia,  and  Raynaud's 
disease  may  develop.  The  importance  of  keeping  in 
mind  this  phase  of  feminiae  hfe,  which  is  dependent 
on  natural  involution  and  disturbance  of  internal  secre- 
tion, lies  in  the  fact  that  it  is  temporary,  and  therefore 
hopeful  as  regards  prognosis,  though  due  allowance  and 
suitable  measures  are  necessary  at  the  time  to  prevent 
permanent  damage  to  the  individual's  family  or  social 
relations,  from  mistaken  interpretation  of  possible  unusual 
behaviour. 

The  oncoming  of  old  age  is  marked  by  a  lowering  of 
functional  activity  associated  with  degenerative  changes 
in  the  tissues,  involving  loss  of  elasticity  and  range  of 
action.  Perhaps  the  first  change  appreciable  by  the 
individual  is  that  occurring  in  the  lens,  accompanied 
by  the  recession  of  the  near  point  of  distinct  vision,  till 
convex  glasses  are  required  for  reading  or  any  close  work. 
This  commonly  asserts  itself  at  about  forty-five,  really 
at  the  commencement  of  middle  hfe,  and  delay  in  its 
occurrence  may  be  regarded  as  a  promise  of  long  life, 
for  those  who  have  attained  great  age  have  usually 
deferred  the  need  of  extraneous  aid  to  vision  till  a  much 
later  period.  The  presence  of  myopia,  or  short  sight, 
necessarily  affords  a  favourable  handicap,  since  till  this 
is  exhausted  by  the  decreasing  refractive  power  of  the 
lens  no  extra  converging  power  is  needed,  and  such 
individuals  may  even  be  enabled  to  dispense  with  the 


Introduction  xxv 

glasses  they  have  formerly  used.  On  the  other  hand 
an  unusually  early  or  rapid  development  of  presbyopia 
indicates  some  additional  cause  of  retrogression,  and 
may  connote  the  onset  of  diabetes.  The  appearance  of 
the  arcus  senihs  shows  a  similar  degenerative  change 
in  the  cornea,  and  is  accompanied  by  retrogressive  changes 
in  cartilage  in  various  parts  of  the  body,  especially  the 
joints  and  thorax,  while  fibrous  structures  such  as  tendons, 
aponeuroses,  and  hgaments  become  indurated  and  even 
calcified.  The  elastic  tissue  of  the  lungs  disappears, 
giving  place  to  fibrous  tissue,  and  similar  changes  sooner 
or  later  pervade  the  arterial  system  and  heart.  Thus 
the  earlier  and  more  pronounced  degenerations  affect 
mainly  the  extra-vascular  tissues  inducing  stiffenino- 
and  loss  of  range  of  movement. 

Similar  decay  of  elastic  fibres  occurs  in  the  skin  which 
becomes  loose  or  wrinkled  and  easily  falls  into  folds, 
ceasing  to  brace  the  subcutaneous  tissues  and  maintain 
the  regular  and  sharp  outline  of  youth.  At  no  point 
does  the  appearance  of  age  show  itself  with  such  certainty 
as  at  the  side  of  the  neck  below  the  angle  of  the  jaw, 
where  the  slack  integument  fails  to  adapt  itself  to  the 
prominences  and  sulci  so  apparent  there.  The  sebaceous 
and  sudoriferous  glands  disappear,  so  that  the  surface 
becomes  dry,  and  sweating  is  almost  or  completely 
abohshed. 

This  change  in  the  skin  and  its  functions  together 
with  disappearnce  of  fat  renders  the  individual  more 
sensitive  to  cold,  which  his  lowered  vitaHty  is  unable  to 
counteract ;  hence  elderly  people  are  often  troubled  about 
draughts  and  night  air,  in  a  way  the  more  vigorous  are 
unable  to  appreciate.  All  the  senses  become  dulled, 
sight,  hearing,  and  touch,  possibly  smell  and  taste  less 
than  the  others.  Reserve  power,  both  in  the  heart  and 
lungs,  is  exhausted,  so  that  any  extra  effort  tells  unduly. 
Sense  of  ec^uilibrium  is  diminished  and  falls  are  more 


xxvi  Introduction 

serious  on  account  of  loss  of  elasticity,  and  greater  fragility 
of  bones  and  fibrous  structures.  The  pulse  becomes 
progressively  slower  from  infancy  to  old  age  as  the  blood 
pressure  rises,  and  febrile  reaction  becomes  less  and  less 
marked,  particularly  the  surface  temperature,  rendering 
the  recognition  of  acute  disease  increasingly  difficult. 

The  capacity  for  digesting  food  and  metabolic  activity 
are  reduced,  so  that  the  maintenance  of  nutrition  is  a 
difficult  problem, 

Not  only  must  the  quantity  of  food  taken  be  small,  but 
the  proportion  of  nitrogen  constituents  should  be  dimi- 
nished and  the  articles  selected  should  be  readily  as- 
similable and  really  nutritious. 

An  approach  to  the  dietary  of  early  childhood  re- 
presents what  is  required  without  the  saccharine  in- 
gredients. 

Owing  to  the  weakened  power  of  digestion,  rest  before 
and  after  meals  is  very  necessary,  and  the  habit  of  dozing 
on  these  occasions  appears  less  injurious  to  the  aged  than 
it  often  is  in  earlier  years. 

Stimulants  in  small  quantity  and  suitable  form  are 
generally  beneficial  especially  towards  the  end  of  the  day. 

Though  elderly  people  commonly  sleep  indifferently, 
they  need  a  good  deal  of  rest,  and  this  is  best  taken  in 
bed  as  being  more  secure  from  change  of  temperature, 
which  is  all  the  more  dangerous  during  sleep.  A  definite 
routine,  so  trying  to  the  young,  is  acceptable  to  old  people, 
who  like  to  adhere  to  habits  and  to  know  what  to  expect. 
Indeed  they  commonly  resent  having  their  customary 
ways  interfered  with. 

But  it  is  the  temperamental  change  in  advancing 
age  which  is  perhaps  most  general  and  conspicuous,  and 
/  this  is  characterised  in  health  by  a  tendency  to  delibera- 
tion and  placidity,  possibly  even  contentment. 

I  recall  once  hazarding  the  statement  that  no  one 
was  really  content  till  he  had  thoroughly  made  up  his 


Introduction  xxvii 

mind  that  he  could  not  have  what  he  wanted.  "  When  I 
arrived  at  that  stage,"  replied  an  eminent  physician,  "I 
should  regard  myself  as  the  subject  of  calcified  cerebral 
arteries."  This  probably  sums  up  the  situation,  for  as 
long  as  vigour  and  enterprise  exist  there  will  be  straining 
after  the  unattainable,  and  the  contentment  of  old  age 
probably  represents  the  accepted  inability  and  even 
desire  for  betterment,  associated  with  emotional  quietude 
and  dependent  on  retrogressive  changes  in  the  cerebral 
circulation. 

In  childhood  superabundant  energy  finds  sufficient 
satisfaction  in  restless  and  aimless  functional  activity, 
later,  in  adolescence,  focussing  itself  in  attempts  to  excel 
in  competition  with  others. 

In  middle  age  sufficient  effort  is  concentrated  upon 
what  is  useful  and  necessary  in  the  needs  of  life,  while 
as  age  advances  effort  becomes  irksome,  and  is  called 
forth  only  by  the  need  of  retaining  what  has  been  already 
acquired. 

The  desire  of  most  people  is  to  extend  the  span  of 
life,  or  at  least  the  period  of  active  enjoyment  and  utility. 
Though  the  hands  of  the  clock  cannot  be  put  back,  they 
may  possibly  be  retarded,  and  this  is  most  likely  to  be 
effected  by  adapting  the  dietary  to  the  period  of  life  both 
as  regards  quantity  and  quality,  as  has  been  already 
indicated.  It  is  advisable  also  to  adhere  as  long  as 
practicable  to  the  mode  of  life  of  each  phase  as  it  reaches 
completion.  In  adult  life  the  exercises  and  amusements 
of  youth  should  be  continued  as  far  as  circumstances 
and  bodily  vigour  permit,  or  those  more  deliberate  field- 
sports  adopted  which  conform  to  the  ability  of  the 
individual  when  the  more  active  games  are  no  longer 
possible ;  these  may  be  continued  through  life,  serving  to 
maintain  the  freedom  of  movement  of  the  limbs  and  body, 
as  well  as  the  health  and  vigour  of  the  internal  organs 
and  the  elasticity  of  the  mind.     It  is  a  rare  relief  from 


xxviii  Introduction 

the  pressure  of  business  and  obtrusion  of  various  troubles, 
to  turn  to  the  river  or  the  golf  green  and  the  fresh  associa- 
tions of  the  country. 

The  same  may  be  said  of  more  serious  occupation, 
which  should  not  be  given  up  completely,  though  it 
may  be  relieved  of  many  of  its  more  arduous  and  monoto- 
nous features,  so  long  as  the  individual  can  follow  it. 
Adherence  to  the  ways  and  habits  to  which  one  has  be- 
come accustomed  tends  to  the  prolongation  of  life  and 
the  avoidance  of  ennui,  for  elderly  folk  cannot  readily 
find  means  to  employ  an  indefinite  amount  of  leisure. 
The  alternative  to  dying  in  harness  is  to  retire  at  an  age 
when  sufficient  energy  and  initiative  remain  to  apply  to 
some  more  congenial  mode  of  life  or  the  pursuit  of  a 
favourite  hobby. 

What  has  been  said  of  men  in  relation  to  their  occupa- 
tion applies  in  many  cases  to  women  in  family  life,  who 
have  devoted  their  interest  and  energy  to  their  children 
and  domestic  affairs  to  the  exclusion  of  everything  else. 
For  them  a  time  comes  when  such  cares  and  occupations 
cease  in  the  natural  course  of  events,  and,  without  an 
alternative  claim  on  attention,  interest  in  life  is  apt  to 
wane. 

The  result  in  both  is  likely  to  be  the  same — absence 
of  outlook,  restless  discontent,  leading  to  relative  over- 
exertion, or  subsidence  into  a  melancholy  quietude. 
Physically  there  commonly  ensues  dilatation  of  the  heart, 
entailing  failure  of  circulation,  associated  with  dropsy, 
which  a  woman  may  survive,  but  a  man  never.  This  is 
perhaps  to  be  broken-hearted. 

"  The  grief  that  does  not  speak 
Whispers  the  o'erfraught  heart 
And  bids  it  break." 


MINOR    MEDICINE 


CHAPTER   I 
THE   DIGESTIVE   SYSTEM 

In  considering  minor  disorders  of  tlie  digestive  system, 
it  is  often  extremely  difficult  to  allocate  definitely  the 
trouble  in  any  particular  organ,  subjective  symptoms 
affording  very  insecure  ground  for  such  discrimination, 
and  the  several  processes  involved  being  so  closely  inter- 
woven that  irregularity  in  one  may  produce  even  more 
conspicuous  disturbance  of  another,  and  some  compre- 
hensive feature,  such  as  portal  congestion,  may  affect 
several  at  once. 

Under  the  term  '*  LiveP  "  are  popularly  grouped  such 
features  as  flatulence,  dyspepsia,  and  constipation,  due 
to  excesses  in  diet  or  stimulants,  which  really  indicate  the 
presence  of  catarrh,  congestion  or  subacute  inflammation 
in  the  stomach  or  intestine ;  while  the  occurrence  of  slight 
jaundice,  clouded  complexion,  and  mental  depression 
are  probably  due  to  constipation  or  to  some  interference 
with  the  free  flow  or  elimination  of  bile,  resulting  from 
catarrh  of  the  ducts,  and  the  resorption  of  this  fluid  with 
crude  or  toxic  constituents  into  the  general  cnoulation. 

Headache,  giddiness,  malaise,  muscular  debility, 
mental  depression,  and  irritability  indicate  the  effect  of 

1 


Minor  Disorders  of  Digestion 


e>* 


such  toxines  on  the  nervous  system ;  while  piles,  weight 
in  the  right  hypochondrium,  and  pain  about  the  right 
shoulder-blade  may  be  due  to  congestion  of  the  hver  or 
even  slight  hepatitis,  shoulder  pain  being  referred  through 
the  connections  of  the  splanchnics  with  the  lower  six 
dorsal  nerves. 

The  activity  and  reserve  power  of  the  liver  doubtless 
vary  in  different  individuals,  as  do  their  capacities  in  other 
directions.  The  influence  of  habit  and  idiosyncrasy  is  also 
marked.  Moreover,  functions  that  can  be  relied  on  in 
certain  conditions  of  health,  activity,  and  period  of  life 
may  prove  totally  inadequate  in  others — as  when  a  diet  of 
beef  and  beer  agrees  well  with  a  man  enjoying  a  vigorous 
country  life,  but  will  not  suit  the  same  individual  in  the 
physically  Isss  active  existence  of  town,  or  when  years 
have  diminished  the  efficiency  of  his  organs.  CHmate  and 
season,  too,  exert  a  powerful  influence  in  the  balance 
between  the  cha^x^acter  and  quantity  of  food  and  the 
functional  capacitj^  of  the  digestive  organs,  so  that  what 
is  necessary  and  suitable  in  some  circumstances  may 
prove  actually  injurious  in  others. 

A  Bilious  Attack  usually  comes  on  in  the  morning, 
often  after  a  disturbed  night  in  which  sleep  is  broken  or 
attended  by  dreams  of  a  depressing  or  terrifying  nature. 
This  may  follow  on  an  extraordinary  repast,  sometimes 
a  meal  which  has  been  accompanied  by  emotional  disturb- 
ance, or  taken  hurriedly  or  when  overfatigued.  Some- 
times it  occurs  in  hot  or  thundery  weather,  in  an  east  wind, 
or  in  connection  with  a  visit  to  the  seaside.  In  some 
people  even  falling  asleep  soon  after  eating  will  bring  on 
an  attack ;  but  to  those  who  are  predisposed,  any  or  no 
cause  may  be  assigned.  Such  as  are  admitted,  however, 
point  to  arrested  or  disturbed  digestion,  associated  with 
disordered  secretion  and  probably  toxic  fermentation. 

The  first  symptoms  noticed  are  malaise,  headache,  and 
disturbance  of  temper,  the  merest  trifles  causing  great 


A  Bilious  Attack  3 

irritation  or  unreasonable  depression  ;  there  may  be  also 
vertigo,  muscae  volitantes,  muscular  debility,  and  entire 
lack  of  interest  or  ability  to  fix  the  attention.  The  healthy 
colour  of  the  skin  is  replaced  by  a  muddy  pallor,  with  dark 
rings  round  the  eyes  and  dryness  of  the  skin  and  hair. 

Appetite  is  lost,  and  there  is  commonly  nausea  ;  if  an 
attempt  is  made  to  eat,  food  tastes  bitter  and  unpalatable, 
disapprobation  being  extended  to  the  cook.  Even  if  the 
morning  meal  has  been  restricted  to  tea  and  toast,  it 
usually  disagrees,  giving  rise  to  flatulence  and  discomfort, 
and  is  very  commonly  rejected,  the  vomit  including  some 
portion  or  the  whole  of  the  meal  taken  overnight, 
accompanied  by  a  good  deal  of  mucus  with  bile,  which 
may  be  green  or  yellow,  having  an  acrid,  bitter  taste. 

The  act  of  retching  is  preceded,  accompanied,  and 
followed  by  nausea  and  prostration  with  cold  sweats, 
the  patient  feeling  at  this  stage  as  miserable  as  possible. 
Diarrhoea  or  constipation  may  follow,  while  the  other 
symptoms  continue  through  the  day,  totally  unfitting  the 
individual  for  any  sort  of  occupation  or  amusement, 
so  that  he  generally  chooses  to  remain  in  bed  or  sit  in 
a  darkened  room,  alternately  dozing  and  concerning 
himself  with  the  exigencies  of  his  disorder. 

As  to  the  pathology  of  this  condition,  only  inferences 
can  be  drawn,  as  no  ocular  demonstration  of  the  state  of 
the  viscera  is  obtainable.  Two  features,  however,  appear 
to  be  definite,  and  constantly  present.  One  is  that  the 
digestive  apparatus  is  on  strike,  as  may  be  deduced  from 
the  complete  anorexia,  the  arrest  of  digestive  processes, 
and  the  absence  or  inversion  of  peristalsis,  resulting  in 
vomiting  and  regurgitation  of  bile  through  the  pylorus. 
The  other  is  the  presence  of  catarrh,  quantities  of  mucus 
being  thrown  up  with  the  undigested  food,  or  independently 
by  retching.  In  the  absence  of  the  normal  secretions 
and  functional  activity  there  is  undoubtedly  a  vast 
increase    in    micro-organisms    associated    with    morbid 


4  Secretion  and  Reabsorption  of  Bile 

fermentation,  producing  lactic  and  butyric  acids  and  other 
unwholesome  products,  whicli  induce  tlie  nervous  and 
other  symptoms  attributed  to  toxic  absorption.  A  bUious 
attack  is  therefore  to  be  regarded  as  a  transient  catarrh 
of  the  gastro-duodenal  area,  associated  with  arrest  of  the 
digestive  function  and  the  development  of  morbid  products 
of  fermentation  and  perverted  digestion,  which  are 
absorbed  into  the  circulation  unchanged,  owing  to  the 
protective  action  of  the  liver  being  suspended. 

It  is  appropriate  to  recall  in  this  connection  some 
features  of  the  bile  and  its  circulation.  When  a  biliary 
fistula  is  established,  it  is  noticed  that  there  is  at  first  a 
copious  escape  of  that  fluid,  but  in  the  course  of  a  few 
days  the  quantity  diminishes  greatly,  and  moreover  the 
amount  secreted  varies  from  day  to  day,  from  which  it  is 
inferred  that  the  bile  secretion  and  with  it  the  functional 
activity  of  the  liver  is  not  uniform,  and  that  a  condition 
which  has  been  termed  torpidity  of  the  liver  may  exist. 

The  falling  off  in  the  quantity  and  depth  of  colour  of 
the  bile  as  a  result  of  continual  escape  through  a  fistula  is 
evidence  that  a  large  portion  of  the  natural  secretion, 
under  normal  conditions,  is  reabsorbed  with  the  products 
of  digestion :  in  the  case  of  fats  it  is,  indeed,  the  vehicle 
by  which  they  are  taken  up  into  the  circulation,  the 
bile  being  returned  into  the  intestine  again  and  again. 
Thus  the  hver  provides  afresh  perhaps  not  more  than 
a  tenth  part  of  that  which  is  daily  passed  through  the 
ducts,  nine-tenths  being  old  bile  returned  from  the  hver 
to  be  used  again. 

This  aspect  of  the  bile  circulation  to  and  fro  between 
the  liver  and  intestine  suggests  another  cause  of  bilious 
attacks,  which  is  independent  of  external  influences,  such 
as  have  been  suggested — that  is,  the  cumulative  efiect  of 
toxic  products  of  imperfect  digestion ;  the  stale  bile 
becoming  more  and  more  deeply  charged  with  them,  when 
the  bowels  are  not  acting  efficiently,  and  they  are  not 


Portal  Circulation  5 

eliminated.  For  it  need  not  be  supposed  that  the 
protective  action  of  the  liver,  as  exemplified  after  the  in- 
gestion of  snake  venom  and  other  poisons,  is  entirely  due 
to  complete  destruction  of  these  substances,  but  rather  to 
their  return  to  the  intestine,  whence  in  the  course  of  time 
they  are  evacuated.  So  long  as  they  are  prohibited  access 
to  the  general  circulation  by  the  selective  if  not  destructive 
power  of  the  liver  cells,  the  organism  is  safe,  and  the 
beneficial  influence  of  purgatives,  in  these  and  allied 
circumstances,  substantiates  this  view,  as  does  the  elimina- 
tion by  the  bowel  of  such  metallic  poisons  as  lead,  assisted 
by  the  same  agency. 

Another  point  worthy  of  consideration  in  connection 
with  temporary  derangements  in  which  the  liver  is  directly 
or  indirectly  concerned  is  the  peculiar  character  of  the 
portal  circulation.  Nowhere  else  in  the  body  except  in 
the  kidney  do  we  find  a  double  capillary  system  interposed 
between  the  afferent  and  efferent  vessels,  and  the  dis- 
advantage of  the  arrangement  from  a  circulatory  point 
of  view  is  demonstrated  by  the  constant  failure  of  these 
two  systems  in  chronic  cardiac  disease,  resulting  in  the 
one  case  in  ascites  and  in  the  other  in  anasarca,  while 
the  functions  of  the  organs  are  seriously  disturbed.  When 
the  circulation  through  an  ordinary  capillary  is  watched 
and  the  variation  in  rate  of  flow  with  the  systole  and  dia- 
stole of  the  heart  is  observed,  it  must  be  realised  how  great 
is  the  disadvantage  in  the  portal  capillaries  with  no  such 
vis  a  tergo  behind  them,  but  only  thin-coated  valveless 
veins  peculiarly  liable  to  variations  in  calibre,  and  relatively 
unsupported  by  surrounding  tissues,  while  they  are  ex- 
posed to  gross  variations  in  pressure  as  exercised  by 
the  abdominal  muscles  and  the  diaphragm,  and  to 
the  influence  of  the  nervous  system,  as  in  shock  or 
collapse. 

Dilatation  of  the  portal  vein  and  its  tributaries  no 
doubt  allows  of   the  accumulation  of  the  products  of 


6  Treatment 

digestion  in  the  intervals  of  meals,  and  of  their  gradual 
subjection  to  the  action  of  the  liver,  the  portal  system 
acting  as  a  reservoir,  thus  assisting  in  converting  nutrition 
from  an  intermittent  into  a  continuous  process.  These 
reflections  would  lead  one  to  the  conclusion  that  great 
variations  in  the  rate  of  the  portal  circulation  are 
possible,  both  with  and  independently  of  the  process  of 
digestion,  the  nutrition  of  the  liver  cells  and  tissues 
being  independently  provided  for  by  the  hepatic  artery. 

The  usual  treatment  adopted  during  these  crises  and 
its  success  are  fully  in  accord  with  these  views.  It  consists 
(i)  in  relieving  the  system  by  starvation  and  purgatives 
or  even  emetics,  though  in  acute  attacks  vomiting  occurs 
spontaneously;  (ii)  in  aiding  the  elimination  of  toxic 
material  by  diluents  ;  and  (iii)  in  controUing  the  local  fer- 
mentation changes  by  antiseptics. 

Practically  these  results  are  obtained  by  the  use  of 
mercurial  and  saline  purgatives,  abstinence  from  food, 
and  drinking  freely  of  some  alkaline  aerated  water. 

The  mercurial  preparations  commonly  employed  are 
calomel,  grey  powder,  or  blue  pill  in  doses  of  gr.  ij-iv, 
given  preferably  at  night.  A  very  convenient  and  effective 
pill  is  composed  as  follows : 

^.  Pil.  Hydrarg gr.  iij 

Ext.  Aloes    .        ,        .        .        .       gr.  j 
Ext.  Hyoscyam gr.  j 

or  in  a  mild  case  a  compound  rhubarb  pill  will  suffice. 
It  is  usual  with  mercury  to  administer  a  saline  draught 
in  the  morning  to  ensure  active  clearance  of  the  bowel. 
The  ordinary  black  draught,  a  seidlitz  powder,  or  a 
sufficient  dose  of  one  of  the  aperient  mineral  waters 
such  as  Condal,  Hunyadi,  Apenta,  or  Friedrichsall, 
or  a  drachm  or  two  of  sulphate  of  soda  or  magnesia, 
answer  very  well,  Besides  drug  treatment,  however, 
it  is  well  to  advise  the  patient  to  do  without  food  for 


Treatment  7 

twenty-four  hours,  or  even  longer  should  recovery  be 
delayed.  Milk  may  be  given  in  small  quantities,  and 
perhaps  a  little  soup  or  beef  tea,  but  the  less  the  better., 
and  the  inclination  is  usually  entirely  wanting,  so  that 
abstinence  is  less  difficult.  As  improvement  occurs, 
the  milk  may  be  given  hot  with  arrowroot,  Revalenta 
arabica,  or  cornflour,  and  junket  and  blancmange  may 
be  added.  In  regard  to  drinking  the  case  is  different ; 
if  there  is  vomiting  there  will  be  thirst,  and  in  any  case 
the  mouth  is  uncomfortable.  Mineral  waters  simply 
aerated,  such  as  Seltzer,  Salutaris,  or  Perrier  water,  may  be 
taken  ;  the  addition  of  a  little  fresh  lemon  is  agreeable 
and  refreshing  to  the  mouth,  but  it  does  not  consort  well 
with  the  milk  and  should  not  be  taken  in  too  close  proxi- 
mity with  it. 

Alkaline  waters  have  the  advantage  in  assisting  to 
liberate  the  mucus  of  which  there  is  an  excess  in  the 
stomach,  and  of  reducing  any  acidity ;  the  most  popular 
are  Potash  or  Soda,  Apollinaris  and  Vichy.  The  addition 
of  sulphate  of  soda  or  magnesia  in  the  proportion  of  a 
drachm  to  the  pint  where  the  bowels  are  not  loose  is 
useful,  though  it  does  not  improve  the  taste. 

Stimulants  are  to  be  avoided,  that  is  to  say,  alcohol 
in  any  form  makes  matters  worse.  If  there  is  great 
prostration  and  depression,  carbonate  of  ammonia  in 
doses  of  10  grains  added  to  nearly  a  tumblerful  of  milk 
is  useful.  Acute  attacks  usually  pass  off  in  twenty-four 
hours  or  so,  and  may  not  be  so  bad  as  to  completely 
disable  the  patient  from  attending  to  minor  affairs ; 
moreover,  if  experience  has  taught  him  to  foretell  or 
expect  a  paroxysm  overnight,  he  may  anticipate  the 
treatment  as  well  as  the  disorder,  and,  by  taking  the 
remedies  prescribed  above  at  once,  may  prevent  the 
attack  or  cut  it  short.  Though,  in  most  cases,  of  infrequent 
and  irregular  occurrence,  some  individuals  are  subject  to 
bilious  attacks  at  intervals  of  a  few  days,  scarcely  passing 


8  '^ The  Blues" 

a  wliole  week  without  symptoms,  and  in  such  the  treat- 
ment should  correspond,  being  adopted  once  or  twice  a 
week,  though  possibly  in  a  modified  form.  For  instance, 
the  mercurial  may  be  reduced  to  one-tenth  of  a  grain  of 
calomel  as  a  lozenge  twice  or  three  times  in  the  course 
of  the  day,  followed  by  compound  liquorice  powder; 
or  a  pUl,  composed  of  a  quarter  of  a  grain  each  of  iridin, 
euonymin,  and  podophyllin,  may  be  substituted,  with 
prepared  Carlsbad  salts,  which  should  be  taken 
several  mornings  in  succession  and  at  such  intervals 
as  may  correspond  with  the  recurrence  of  the  dis- 
order, once  a  month  being  sometimes  sufficient.  When 
very  persistent  and  disabling,  a  course  of  treatment  at 
one  of  the  special  watering-places  is  to  be  recommended, 
where  the  routine  life,  limited  diet,  and  appropriate  salts 
diluted  with  large  quantities  of  water  are  combined 
with  moderate  exercise  and  quiet  amusement. 

Besides  these  acute  attacks,  which  usually  provide 
their  own  cure  by  loss  of  appetite,  vomiting,  and  diarrhoea, 
there  appears  to  be  a  subacute  and  more  prolonged  con- 
dition of  the  same  kind,  known  in  the  vernacular  as  the 
**  Blues."  This  consists  of  a  group  of  symptoms  including 
mental  depression,  irritability,  vacillation,  and  inabihty 
to  fix  attention  or  take  any  interest  in  the  usual  occupa- 
tions or  amusements ;  there  is  generally  loss  of  appetite, 
but  sometimes  morbid  hunger;  the  ingestion  of  food, 
however,  not  being  attended  with  satisfaction  and  being 
commonly  followed  by  some  symptoms  of  indigestion. 
It  may  last  two  or  three  days,  and  either  pass  off  or 
culminate  in  a  regular  bilious  attack.  Headache,  cutane- 
ous irritation,  an  unhealthy  aspect  of  the  skin  and 
conjunctiva,  and  constipation  with  high-coloured  urine, 
often  loaded  with  urates  coexist,  and  appear  to  depend, 
as  in  the  former  conditions,  upon  the  accumulation 
of  digestive  by-products  and  defective  renewal  of  bile ; 
there  is  possibly  also  some  catarrh  of  the  storaach  and 


Chill  on  the  Liver  9 

duodenum  with  retardation  of  the  portal  circulation. 
Drowsiness  in  the  day  and  unsatisfactory  sleep  at  night 
are  also  common  features  of  the  complaint,  which  is  apt 
to  supervene  on  loss  of  accustomed  exercise  or  too  close 
adhesion  to  routine  life,  perhaps  combined  with  relative 
excess,  in  eating  and  drinking.  The  remedies  suggested 
in  the  foregoing  paragraph  are  equally  effective  here, 
but  need  not  be  quite  so  di'astic.  The  compound  rhubarb 
pill  two  or  three  nights  in  succession,  the  blue  pill  with 
aloes  and  hyoscyamus  or  gr.  j-ij  of  calomel,  followed  by 
a  saline  such  as  citrate  of  magnesia  in  the  morning,  with 
a  limited  farinaceous  diet  and  a  more  free  use  of  either 
plain  water  or  one  of  the  mineral  waters  usually  suffice. 
The  plan  of  drinking  a  tumblerful  of  hot  water  an 
hour  before  each  meal  so  as  to  wash  out  the  stomach 
and  upper  part  of  the  intestine  is  beneficial. 

A  Chill  on  the  Livep. — This  is  a  diagnosis  com- 
monly made  by  the  patient  and  possibly  accepted  by  the 
medical  man  as  a  doubtful  entity.  As  in  most  functional 
derangements,  there  are  no  definite  objective  symptoms, 
but  the  subjective  ones  are  numerous  and  are  similar  to 
those  already  enumerated.  The  mental  depression  and 
loss  of  physical  energy  are  more  marked,  and  a  sense  of 
weight,  discomfort,  or  pain  is  complained  of  in  the  right 
hypochondrium  and  epigastrium,  and  at  the  back  under 
the  shoulder-blade  or  in  the  interscapular  region.  There 
is  a  tendency  to  coldness  of  the  extremities  and  the  face 
often  has  an  ashy  colour  and  pinched  look.  The  bowels 
are  constipated,  the  urine  scanty  and  loaded  with  Hthates, 
appetite  is  lacking,  and  digestion  attended  with  discomfort. 
Some  dilatation  of  anal  veins  may  occur.  The  duration 
of  this  state  when  untreated  is  indefinite  unless  dispelled 
by  change  of  atmosphere  or  climate,  continuing  two  or 
three  weeks  or  even  a  month.  The  onset  appears  to  be 
determined  by  cold  and  inactivity,  and  is  often  associated 
with  the  prevalence    of    a  north-east  wind,   sedentary 


lo  Flatulence 

occupation  in  a  cold  room,  or  a  long  railway  journey. 
Here,  again,  tlie  pathology  is  only  a  matter  of  inference, 
but  both  cause  and  effect  are  in  accord  with  the  supposi- 
tion that  there  is  congestion  of  the  portal  system  with 
slowing  of  the  circulation  through  the  liver  and  chronic 
catarrh  of  the  mucous  membrane  of  the  digestive  tract. 

The  most  effective  treatment  in  addition  to  measures 
for  unloading  the  abdominal  venous  system  and  adapting 
nourishment  to  a  diminished  digestive  capacity,  as  in 
the  former  disorders,  is  the  application  of  external  heat, 
which  is  best  applied  as  a  hot-water  or  Turkish  bath, 
prolonged  beyond  the  ordinary  time  on  three  or  four  days 
in  succession,  the  skin  being  thoroughly  reddened  and 
perspiration  encouraged.  As  a  sense  of  chilliness  is  a 
feature  of  the  disorder,  this  is  agreeable,  and  an  immediate 
sense  of  relief  follows,  but  repetition  is  necessary  to  ensure 
permanence,  and  anything  in  the  form  of  cold  douche 
should  be  omitted.  In  spite  of  the  low  spirits  alcoholic 
stimulants  are  to  be  avoided,  except  in  the  form  of  hot 
spirit  and  water  at  night  to  promote  the  action  of  the  skin 
on  going  to  bed.  Carbonate  of  ammonia  or  sal  volatile 
in  fairly  full  doses  well  diluted,  as  in  a  glass  of  milk,  may 
be  taken  during  the  day. 

Flatulence  (Tympanites). — ^The  condition  of 
gaseous  distension  in  the  digestive  tract  is  a  very  common 
one,  and  leads  to  great  discomfort  and  even  danger  by 
disturbance  of  the  respiration  and  circulation,  through 
upward  displacement  of  the  diaphragm  and  embarrass- 
ment of  the  thoracic  viscera,  but  even  more  by  interfering 
with  the  propulsion  of  the  intestinal  contents  and  inducing 
actual  obstruction.  Kinking  and  volvulus,  or  twisting 
of  the  gut,  has  supervened  on  this  distension,  and  it  is 
often  the  exciting  cause  of  the  onset  of  the  symptoms 
in  patients  with  obstructive  lesions. 

Mere  confinement  to  bed  in  those  unaccustomed  to 
sickness,    or   invalid    diet,    may   cause   this   distressing 


Treatment  1 1 

symptom,  which  is  variously  alluded  to  as  tympanites  or 
meteorism.  The  same  may  result  from  the  action  of 
purgatives,  and  it  is  also  found  in  many  diseases, 
especially  typhoid  fever,  and  as  an  after-effect  of 
abdominal  operations. 

The  accumulation  of  gas  may  be  limited  to  the  stomach 
or  colon,  or  may  be  generally  distributed  throughout  the 
digestive  tract.  Sometimes  it  appears  to  be  due  rather 
to  paralysis  and  relaxation  of  the  muscular  walls  of  the 
gut  or  abdomen  than  to  the  actually  increased  pressure 
within,  and  its  rapid  occurrence  marks  the  last  stage 
of  acute  and  fatal  illness.  This  is  especially  the  case 
in  unfavourable  issues  in  pneumonia  and  other  acute 
diseases,  or  in  collapse  after  severe  injury  or  operation. 
Observant  nurses  have  been  wont  to  note  how  in  such 
instances  liquids  ingested  appear  to  fall  direct  into  the 
stomach  with  an  audible  gurgle  or  splash  instead  of 
being  grasped  by  the  gullet  and  swallowed  in  the  ordinary 
way,  and  they  correctly  anticipate  a  speedily  fatal  event. 

The  rapid  extension  of  the  area  of  stomach  resonance 
till  it  actually  reaches  the  pubes  corresponds  with  the 
previous  observation ;  and  whether  limited  to  the 
stomach  or  involving  the  intestines,  such  rapid  develop- 
ment of  gaseous  distension,  associated  as  it  is  with  pro- 
found nervous  prostration,  is  of  the  gravest  augury.  As 
a  concomitant  of  acute  and  chronic  intestinal  obstruction 
and  peritonitis  this  symptom  is  only  too  familiar,  and  is 
one  of  the  chief  bars  to  recovery  after  operation. 

In  such  desperate  and  critical  conditions  which  com- 
monly preclude  the  administration  of  remedies  by  the 
mouth,  recourse  must  be  had  to  the  subcutaneous  in- 
jection of  strychnine  in  paralytic  or  of  atropine  in  spas- 
modic states.  The  introduction  of  an  oesophageal  tube 
by  the  mouth  in  acute  gastric  distension  or  by  the  rectum 
in  that  of  the  intestines  has  sometimes  secured  relief ; 
other  remedies  which  have  been  efficacious  are  the  Enem^ 


12  Minor  Degrees  of  Flatulence 

Terebinthinse  (5  iv  with  mucilage  or  barley  water  to 
5  vj),  Enema  Asafetidse  gr.  xxx,  and  the  Enema  Rutse 
TIL  XXX  (diluted  in  the  same  manner).  In  a  thin  subject 
with  coils  of  intestine  visible  through  the  abdominal 
wall,  gas  has  been  directly  liberated  by  puncture  with 
a  fine  trochar  and  canula,  but  such  a  proceeding  has 
obvious  risks. 

In  patients  confined  to  bed  the  warmth  and  pressure 
afforded  by  a  rubber  or  flat  metal  container  filled  with 
hot  water  are  comforting  and  sometimes  curative. 

The  occasions,  however,  which  it  is  chiefly  intended 
to  allude  to  here  are  those  either  of  acute  attacks  resulting 
from  some  departure  from  customary  diet,  or  chronic 
or  recurring  attacks  associated  with  the  continued 
ingestion  of  unsuitable  food,  or  other  causes. 

In  the  stomach  flatulence  is  due  to  fermentatioil 
of  carbohydrate  or  saccharine  matters  associated  with 
delayed  or  disordered  digestion,  or  when  occurring  im- 
mediately after  a  meal  may  result  from  direct  liberation 
of  gas  from  excess  of  carbonate  of  soda  employed  in 
the  preparation  of  the  food. 

The  effect  of  gastric  distension  is  a  feeling  of  tightness 
and  fulness  with  actual  bulging  in  the  epigastrium  and 
left  hypochondrium,  palpitation  of  the  heart,  a  sense  of 
oppression  in  the  chest,  and  often  flushing  and  burning 
in  the  face,  some  temporary  relief  being  obtained  at 
intervals  by  eructation.  There  is  always  hyperacidity 
of  the  gastric  contents,  and  the  regurgitation  of  acid  fluid 
through  the  cardiac  orifice  may  add  the  sensation  of 
heartburn  to  the  other  discomforts. 

When  the  general  mass  of  the  intestines  is  involved, 
there  is  more  uniform  bulging  of  the  abdomen  with  c. 
wider  distribution  of  pain  or  discomfort,  but  this  is  a 
rare  event  apart  from  the  more  serious  condition  involved 
in  obstruction  and  peritonitis. 

Chronic  or  recurring  inflation  of  the  colon  is  commonly 


Enterospasm  13 

associated  with  constipation  and  generally  accompanied 
by  the  discharge  of  flatus  per  anum.  This  condition 
is  responsible  for  the  continual  development  of  those 
"  intestinal  croakings  "  known  as  borborygmi  which  are 
excited  by  the  peristalsis  of  the  intestine,  and  also  by 
the  movements  of  the  diaphragm  and  of  the  abdominal 
muscles  in  respiration. 

At  the  hepatic  and  splenic  flexures,  and  sometimes 
also  in  the  sigmoid,  sharp  horseshoe  curves  attended 
by  kinking  and  muscular  spasm  lead  to  local  stasis  and 
distension,  which  give  rise  to  great  discomfort  often 
unrelieved  for  hours  by  any  escape  of  the  imprisoned  gas. 
These  attacks  appear  to  be  induced  by  articles  of  diet  for 
which  the  patient  has  an  unfavourable  idiosyncrasy, 
and  often  result  from  exposure  to  external  cold  or  the 
ingestion  of  iced  beverages  or  confections ;  even  fruits 
such  as  strawberries  or  pears  may  cause  an  attack.  Besides 
the  local  distension  unrelieved  by  eructation  or  escape  of 
flatus,  these  paroxysms  of  "  Entepospasm,"  as  they 
have  been  called,  are  remarkable  for  their  liability  to  recur 
at  the  same  hour  on  several  successive  days  :  six  o'clock 
in  the  evening  is  a  favourite  time,  and  may  be  connected 
with  the  custom  of  drinking  tea  in  the  afternoon.  As 
already  stated,  flatulence  is  usually  associated  with  acidity, 
and  this  is  specially  liable  to  occur  when  unconsidered 
trifles  are  taken  at  irregular  times,  enough  to  excite 
gastric  secretion  while  insufficient  to  absorb  and  occupy 
it.  It  is  doubtful  also  whether  on  these  irregular  occasions 
the  alkaline  digestive  secretions  of  the  pancreas  and  liver, 
which  should  neutralise  the  contents  of  the  stomach  as 
they  traverse  the  duodenum,  are  excited  in  an  equivalent 
degree,  the  absence  of  bile  being  an  acknowledged  factor 
in  the  production  of  fermentative  changes  and  irregular 
or  insufficient  peristalsis. 

The  remedies  which  have  been  advocated  for  flatulence 
are  as  numerous  as  the  wide  distribution  and  variations 


14  Remedies  for  Flatulence 

in  the  complaint  would  lead  one  to  expect.  Those  which 
exert  an  immediate  local  influence  are  either  antacids 
or  aromatics,  while  those  which  have  a  more  continuous 
and  extended  effect  are  antiseptic,  cholagogue,  or  purga- 
tive. 

As  a  type  of  the  jBrst  class  Sal  Volatile  is  a  good  ex- 
ample and  a  very  popular  remedy ;  half  a  drachm  with 
VI XX  of  Spirits  of  Chloroform  and  vi  x  of  the  Tinctura 
Carminativa  in  water  forms  an  agreeable  and  effective 
dose  in  an  ordinary  attack  of  gastric  flatulence,  or  the 
combination  of  sal  volatile  and  spirits  of  chloroform  with 
bicarbonate  of  soda  and  infusion  of  cloves  in  appropriate 
doses  is  effectual.  Immediate  relief  can  often  be  obtained 
by  taking  two  or  three  drops  of  peppermint  or  cajeput 
oil  on  a  piece  of  sugar,  and  when  the  more  formal  drugs 
are  not  at  command  a  very  good  draught  can  be  extem- 
porised by  pouring  boiling  water  on  four  or  five  crushed 
cloves  in  a  wine-glass,  and  adding  ten  to  twenty  grains 
of  carbonate  of  soda ;  merely  drinking  hot  water  will 
commonly  be  of  benefit,  since  each  time  the  cardia  is 
relaxed  some  pent-up  gas  escapes,  and  much  of  the  effect 
of  the  aromatic  substances,  alcohol,  or  ether  depends  on 
this.  A  compound  rhubarb  pill  followed  by  a  draught 
of  hot  water  exerts  a  relaxing  influence  on  both  the 
oesophageal  and  pyloric  openings,  and  acts  later  as  a 
purgative,  so  that  it  is  probably  the  most  comprehensive 
remedy  where  flatulence  and  distension  are  associated 
with  a  meal  which  disagrees,  either  on  account  of  its 
chemical  or  physical  characters  or  the  temporarily  dis- 
ordered state  of  the  stomach. 

Flatulent  distension  of  the  colon  is  more  difficult  to 
relieve  immediately  by  drugs.  Locally  applied  pressure 
and  heat  exert  the  most  rapid  effect,  but  the  spasmodic 
attacks  known  as  "  Enter ospasm  "  are  often  rapidly 
benefited  by  menthol  given  in  small  doses.  A  pill  com- 
posed of  Menthol  gr.    J,  Calomel  gr.   ^,  with  sufficient 


Heartburn  1 5 

Powdered  Ginger  (gr.  ij)  and  Syrup  of  Glucose  to  make  up 
a  convenient  bulk,  may  be  given  three  times  a  day, 
though  a  single  dose  ensures  relief  in  a  few  minutes.  Com- 
pound menthol  or  soda  mint  tabloids  have  a  similar  effect. 

Heaptbupn. — This  word  well  expresses  the  uncom- 
fortable sensation  which  occurs  behind  the  lower  end 
of  the  sternum  when  the  acid  contents  of  the  stomach 
regurgitate  through  the  cardiac  orifice  into  the  oesophagus. 
It  may  result  from  active  exertion,  lying  down  or  stooping 
just  after  a  meal,  but  may  come  on  independently  when 
there  is  flatulent  distension  of  the  stomach  or  irregular 
secretion  of  acid  with  active  peristalsis.  In  the  latter 
class  of  cases,  which  are  commonly  associated  with 
neurasthenia  or  gout  and  habitual  dyspepsia,  there  may 
be  such  profuse  discharge  of  this  acid  fluid  that  it  is  ejected 
from  the  mouth  almost  as  in  vomiting.  Indeed  the 
contraction  of  the  stomach  with  dilatation  of  the  cardia 
only  lacks  the  simultaneous  compression  by  the  abdominal 
muscles  to  complete  this. 

The  discomfort  itself  may  be  relieved  by  drinking  a 
little  fluid  so  as  to  wash  back  the  acid  into  the  stomach, 
or  corrected  with  a  little  alkali,  such  as  sal  volatile 
or  soda,  the  soda  lozenge  of  the  Pharmacopoeia  being 
specially  useful  on  such  occasions.  In  one  instance  the 
acid  eructations  referred  to  above,  which  had  continued 
off  and  on  for  forty  years,  were  relieved  by  "  Live-long 
tablets,"  an  old-fashioned  mixture  of  soda,  ginger,  rhubarb, 
and  magnesia  made  into  a  sort  of  confection  with  sugar. 
When  these  occurrences  are  frequent,  the  patient  should 
be  advised  to  sit  or  stand  upright  for  some  time  after  a 
meal,  lying  down  or  stooping  tending  to  bring  the  gastric 
contents  against  the  cardia,  but  the  condition  often 
connotes  dyspepsia  with  over-acidity  and  spasm  of  the 
pylorus  or  laxity  of  the  cardia. 

The  modern  view  of  digestion,  aided  by  gastric 
surgery,  has   tended   to   displace  the  stomach  from  its 


1 6  Hiccough 

pre-eminent  position  as  an  organ  of  digestion,  regarding 
it  chiefly  as  a  reservoir  for  food,  which  exerts  some 
antiseptic  power,  and  continues  comminution  by  dissolv- 
ing connective  tissue  and  cement  substance  in  animal 
fibre,  rendering  ingested  matter  more  easily  permeable 
by  the  true  digestive  juices.  Long  retention  of  the 
food  by  contraction  of  the  pylorus,  excess  of  acid  secretion 
or  the  occurrence  of  fermentation,  are  affairs  apart  from 
the  normal  function  of  the  organ,  and  indicate  something 
wrong  either  in  the  stomach  itself  or  in  the  chemical  or 
physical  quahties  of  the  food. 

Hieeoug"!!. — This  uncomfortable  and  sometimes  dis- 
tressing phenomenon  is  produced  by  intermittent  spas- 
modic contraction  of  the  diaphragm,  the  resulting  in- 
spiration being  checked  by  falling  together  of  the  vocal 
cords,  which  are  not  held  open  as  in  inspiration.  It  is 
often  a  terminal  symptom  in  serious  abdominal  states 
such  as  peritonitis  and  intestinal  obstruction,  and  is 
sometimes  a  neurotic  manifestation,  in  such  cases  being 
continued  in  an  exaggerated  fashion  for  weeks,  though 
ceasing  during  sleep  and  capable  of  suppression  by 
disciplinary  measures. 

Under  more  ordinary  circumstances  it  appears  to  arise 
in  connection  with  stomach  irritation,  excited  by  flatu- 
lence, over-distension,  or  indigestible  food,  and  especially 
by  hot  condiments  such  as  pepper  and  curry  powder. 
Active  exertion  immediately  after  a  meal  is  also  a  common 
cause,  and  it  very  frequently  occurs  in  infants  from  too 
hurried  or  excessive  ingestion  of  milk.  The  attacks 
are  not  usually  prolonged,  and  consequently  afford  little 
opportunity  for  trying  drugs,  but  once  started  are  kept 
up  by  expectancy,  so  that  often  the  best  way  of  arresting 
them  is  by  suddenly  diverting  the  attention.  Pressure 
of  the  finger-tip  on  the  cricoid  cartilage  with  slight 
movement  is  often  successful,  and  is  especially  useful  in 
infants,  hiccough  in  them  often  ending  in  vomiting. 


Dyspepsia  17 

In  adults,  drawing  a  deep  breath  and  maintaining 
contraction  of  the  diaphragm  is  usually  effective ;  coutiting 
up  to  a  hundred  without  drawing  breath,  or  taking  several 
sips  of  water  with  a  similar  restriction  answers  nearly  as 
well,  and  is  easier  to  carry  out.  Failing  relief  by  these 
methods,  reliance  may  generally  be  placed  on  the  effect  of  a 
good  sneeze  excited  by  tickling  the  nostril  or  taking  snuff. 

In  really  protracted  cases  apomorphia,  morphia,  and 
pilocarpine  in  full  doses  have  been  injected  with  benefit ; 
inhalations  of  chloroform  or  amyl  nitrite  have  been  given, 
or  firm  traction  on  the  tongue  has  proved  effectual,  tension 
being  kept  up  while  the  period  of  several  spasms  passes. 
If  any  morbid  condition  such  as  distension  of  the  stomach 
or  hyperacidity  coexists,  it  should  be  reheved,  and  lavage 
has  proved  immediately  remedial  in  some  cases. 

Dyspepsia. — Under  the  term  "  indigestion"  are  in- 
cluded a  number  of  uncomfortable  sensations  associated 
with  the  ingestion  and  digestion  of  food,  which  may  be  con- 
sidered under  "  minor  disorders  "  so  long  as  the  objective 
signs  of  wasting,  hasmorrhage,  reaUy  severe  pain,  persistent 
vomiting,  and  the  serious  indications  denoting  perforation 
or  obstruction  in  the  digestive  tract  are  absent.  Apart 
from  these  signs  of  organic  disease,  the  distress  caused  by 
disturbance  of  the  process  of  digestion,  even  when  ex- 
pressed only  by  morbid  sensations,  is  serious  enough  to  call 
for  rehef ,  though  it  is  frequently  borne  for  long  periods  by 
the  patient,  under  the  impression  that  it  is  irremediable 
or  will  pass  off  of  its  own  accord  with  some  change  of  cir- 
cumstances ;  such  an  event  having,  perchance,  come  within 
the  range  of  his  personal  experience.  To  the  medical 
adviser  few  things  are  more  unsatisfactory  to  deal  with 
than  subjective  symptoms,  often  intermittent  in  their 
occurrence  and  dependent  on  a  disturbance  of  balance 
in  the  daily  life  of  a  patient,  who  is  not  sufficiently 
incapacitated  to  put  himself  under  complete  supervision. 
It  is  almost  needless  to  say  that  dyspepsia  occurs  at  aU 

2 


1 8  Dyspepsia 

ages,  commencing  in  infancy  with  the  disagreement  of 
natural  food,  calling  for  the  hundred-and-one  proprie- 
tary articles  which  contend  with  one  another  for  popular 
favour ;  associated  in  childhood  with  insufficient  masti- 
cation usually  accompanying  the  temporary  dentition 
and  increased  by  the  interregnum  prevailing  between 
this  and  the  completion  of  the  permanent  set  of  teeth. 
In  the  period  of  school  life,  when  boys  are  commonly 
allowed  to  bolt  their  food  and  regulate  the  duration 
of  their  meals  by  the  exigencies  of  the  playground, 
the  irregular  ingestion  of  articles  which  are  neither 
particularly  wholesome  nor  nutritious  throws  a  further 
strain  on  the  function  of  the  stomach.  It  is  a  marvel 
to  many  adult  observers  how  the  average  schoolboy  does 
commonly  emerge  scatheless  from  these  as  from  other 
self-imposed  risks.  The  vigour  of  youth  and  absence 
of  over-sensitive  nerves  make  hght  of  gastric  remon- 
strances, if  they  exist,  and  the  facility  of  vomiting,  which 
is  a  feature  of  the  young  throughout  the  animal  kingdom, 
is  an  effective  safety-valve,  a  timely  evacuation  of  the 
stomach  no  doubt  often  affording  escape  from  more 
prolonged  trouble. 

A  common  cause  of  so-called  indigestion  is  insufficient 
interval  between  meals.  We  start  the  day  later,  and 
introduce  more  repasts,  than  did  a  previous  generation, 
to  say  nothing  of  the  ancillary  refreshment  between  them. 
The  stomach  may  be  considered  to  be  never  empty,  it 
gets  no  physiological  rest,  and  any  morbid  fermentation 
that  may  be  set  up  is  inevitably  handed  on  by  the  gastric 
residues  from  one  meal  to  another,  while  the  organ  itself 
does  not  contract,  and  in  not  a  few  instances  appears 
rather  to  dilate  and  lose  its  peristaltic  power.  It  is  worth 
considering  that  in  most  cases  of  indigestion  dependent 
on  functional  causes  the  only  meal  which  may  be  unat- 
tended with  subsequent  discomfort  is  breakfast — that  is, 
the  one  succeeding  the  relatively  long,  foodless  interval 


Dyspepsia  1 9 

of  night.  There  are,  of  course,  other  things  which  throw 
an  undue  strain  upon  the  functions  of  the  stomach,  one 
of  the  commonest  being  "  eating  too  fast."  It  is  unneces- 
sary to  go  into  the  many  motives  for  this,  but  whatever 
they  are,  the  economy  will  not  keep  pace  with  the  volun- 
tary act  of  swallowing.  Mastication,  insalivation,  the 
secretion  of  the  digestive  juices,  the  successive  chemical 
changes  the  food  undergoes  and  its  passage  from  one 
portion  of  the  tract  to  another,  can  neither  be  hurried  nor 
dispensed  with.  To  scamp  the  preliminary  phase  of  the 
digestive  process  in  the  mouth  is  only  to  throw  extra  work 
on  the  rest  of  the  tract,  the  stomach  especially,  work  which 
it  is  neither  suited  nor  prepared  for,  and  consequently 
does  not  perform  ;  so  that  a  large  portion  of  the  food 
thus  hurriedly  taken  is  passed  on  practically  as  foreign 
matter,  not  merely  to  waste,  but  injuring  the  delicate 
mechanism  and  interfering  with  such  normal  processes 
as  may  be  going  on.  Eating  hurriedly,  however,  is  not 
alone  accountable  for  this  crude  interference  with  diges- 
tion. Many  people  are  not  blessed  with  what  the  dentists 
call  "  a  good  bite  "  :  either  there  are  gaps  in  the  teeth  due 
to  loss  or  irregularity,  or  when  the  proper  complement 
is  present  there  is  not  necessarily  satisfactory  contact 
between  the  upper  and  lower  sets.  Then  there  is  the 
character  of  the  food,  which  may  be  so  tough  as  to  defy 
the  strongest  masticatory  powers.  Those  who  are  prone 
to  indigestion  would  find  it  a  good  rule  "  never  to  put  into 
the  mouth  anything  which  resists  a  moderate  use  of  the 
knife  and  fork,  and  never  to  swallow  anything  they  cannot 
bite."  It  is  only  too  common  a  practice  to  get  rid  of 
tough  morsels  by  "  bolting  "  them,  and  to  persist  in  eating 
more  of  what  has  already  proved  refractory  from  motives 
of  politeness,  carelessness,  or  sheer  necessity.  Such  seK- 
sacrifice  may  be  commendable  socially,  but  it  entails 
serious  and  prolonged  suffering  on  the  victim  of  such 
considerations,   and  if   he   is   prone   to   indigestioa    will 


20  Selection  in  Diet 

render  him  miserable  and  uncompamonable  for  horn's 
and  even  days.  Instances  are  known  in  which  grape- 
skins  have  been  found  in  the  stomach  three  months,  and 
the  pulp  of  an  orange  six  months,  after  being  swallowed, 
and  it  is  not  too  much  to  suppose  that  tough  morsels  of 
meat,  doughy  substances  saturated  with  fat,  ill-made 
pastry  and  pudding-crust,  and  various  "  strings  and 
stones,  skins  and  bones  "  will  be  refused  passage  by  a 
sensitive  pylorus  for  hours  or  even  days  ;  in  the  mean- 
time preventing  the  stomach  from  resting,  and  becoming 
the  nucleus  of  fermentative  processes,  which  interfere 
with  the  wholesome  solution  of  successive  meals  and  give 
rise  to  eructation  of  gas  and  the  various  uncomfortable 
sensations  which  constitute  dyspepsia. 

Those  who  possess  irritable  and  sensitive  stomachs  may 
suffer  long  before  they  find  the  remedy  or  the  regimen 
which  reheves  them  or  secures  immunity,  but  they  will 
do  wisely  in  the  long  run  to  eschew  strange  cooks  and 
unaccustomed  dishes  and  to  adhere  to  simple  fare.  In 
the  preparation  of  food  attention  must  be  paid  to  the  due 
hanging  of  meat  before  it  is  cooked,  and  if  this  cannot 
be  accomplished,  it  is  better  to  consume  New  Zealand 
lamb  which  is  imported  aheady  well  hung,  or  else  to 
select  the  inner  organs,  such  as  tripe,  sweetbread,  or  Hver, 
which  are  easier  of  digestion  than  ordinary  meat.  Though 
fish  and  poultry  are  commonly  supphed  to  invahds  as 
being  easier  of  digestion  than  meat,  this  is  not  always 
the  case.  It  should  be  remembered  that  boiling  is 
better  than  baking  or  frying,  and  that  flat  fish  of  all 
kinds  are  more  tender  than  others,  except,  perhaps, 
whiting  or  smelts,  and,  of  course,  oysters. 

But  the  form  of  animal  food  which  is  best  tolerated  by  a 
hypersensitive  stomach  is  milk  in  one  form  or  another  and 
egg  albumen.  They  may  be  diluted  in  various  ways,  or  con- 
verted into  semi-sohds,  such  as  junket,  custard,  or  blanc- 
mange, or  combined  with  starchy  food,  either  predigested 


Remedies  21 

or  not.  When  these  are  rejected  or  give  rise  to  pain,  there 
remains  nothing  but  absolute  starvation  for  a  few  days, 
so  as  to  give  the  stomach  complete  rest  both  in  the  matter 
of  secretion  and  peristalsis.  Thirst  can  be  alleviated  and 
the  comfort  and  bulk  of  the  patient  maintained  by 
enemata  of  warm  water,  the  quantity  being  raised  by 
degrees  to  half  a  pint  every  four  hours.  This,  of  course, 
requires  the  patient  to  be  kept  in  bed  and  rather  exceeds 
the  limit  of  minor  medicine. 

The  commonest  causes  of  attacks  of  dyspepsia  are  the 
ingestion  of  unsuitable  food,  mental  disturbance  such  as 
worry,  annoyance,  and  haste  at  meal-times,  eating  when 
overfatigued,  especially  when  the  patient  falls  asleep 
immediately  afterwards,  and  undue  activity  either 
immediately  before  or  after  eating.  In  one  instance  of  a 
busy  city  man  who  barely  got  through  his  day's  work  in 
time  for  the  evening  meal,  the  late  Sir  Andrew  Clark  gave 
but  one  direction,  "Dress  for  dinner,"  and  this  was  effectual. 

For  the  ordinary  solitary  instances  of  food  disagreeing 
and  perhaps  occasioning  a  disturbed  night,  there  is  no 
remedy  equal  to  the  compound  rhubarb  piU  taken  as 
soon  as  the  disorder  is  recognised.  It  will  restore  peace 
and  comfort,  and  render  the  stomach  fit  for  next  morning's 
breakfast.  For  children  the  compound  rhubarb  powder 
(Gregory's)  answers  the  same  purpose,  and  is  useful  as  a 
disciplinary  measure  as  well  as  a  therapeutical  one. 

Where  the  discomfort  succeeding  meals  is  habitual, 
as  in  nervously  excitable  individuals  over-anxious  about 
studies  in  youth  and  about  other  affairs  in  later  life,  all 
the  precautions  about  taking  food  at  proper  intervals 
and  in  a  proper  state  of  preparation,  both  as  regards  the 
individual  and  the  food,  must  be  observed  ;  but  in  ad- 
dition it  will  often  be  found  that  the  constant  discomfort 
has  led  to  the  elimination  of  one  thing  and  another  from 
the  diet  list,  till  the  patient  is  restricted  almost  entirely 
to  carbohydrate  food  in  the  form  of  bread  and  sweets. 


22        Farinaceous  Food  and  Fermentation 

There  is  commonly  some  tenderness  of  the  stomach 
area  with  distension  and  even  dilatation  of  the  organ 
associated  with  succussion  and  loss  of  peristalsis  and  con- 
tractile power.  These  are  the  very  numerous  cases 
which  benefit  remarkably  by  the  mode  of  treatment 
introduced  by  Dr.  Salisbury  and  named  after  him,  and 
which  consists  in  the  administration  of  raw  meat  finely 
minced  and  lightly  grilled,  in  increasing  quantities  up 
to  half  a  pound  to  a  pound  at  a  time,  nothing  else  being 
allowed  except  hot  water  as  a  beverage  either  some  time 
before  or  after  the  meal.  In  the  majority  of  these  cases 
the  fermentation  of  carbohydrates  is  the  root  of  the  evil, 
and  a  sustained,  purely  nitrogenous  diet  puts  an  end  to 
this,  while  supplying  a  highly  nutritious  food  in  a  small 
space,  and  so  encouraging  the  stomach  to  contract  to 
normal  dimensions. 

Apart  from  this  special  regime,  however,  persistent 
flatulent  dyspepsia  may  often  be  cured  by  omitting  all 
farinaceous  food  for  a  day  or  two  and  subsisting  on 
nitrogenous  material  such  as  meat,  fish,  and  eggs  alone. 
Sometimes  the  restriction  of  each  meal  to  one  class  of 
food,  such  as  fruit,  cereals,  or  meat,  is  found  beneficial. 
Lengthening  the  intervals  between  meals  so  as  to  ensure 
the  stomach  being  empty  before  the  next  is  taken  exerts 
a  powerful  influence  in  correcting  morbid  processes  in 
the  digestive  tract,  and  free  imbibition  of  water,  pre- 
ferably hot,  an  hour  or  more  before  or  after  meals  tends 
to  clear  and  refresh  the  stomach.  Fasting  to  the  verge 
of  actual  hunger  is  a  ready  cure  for  many  functional 
derangements  of  digestion. 

Such  unsuspected  articles  as  bread,  coarsely  made 
as  it  sometimes  is  in  the  country  with  a  good  deal  of 
potato  ;  or  water,  hard  with  an  unusual  amount  of  calcium 
salts,  may  be  the  cause  of  persistent  discomfort.  To 
sum  up,  it  may  be  affirmed  that  digestion  and  fermenta- 
tion go  hand  in  hand  in  the  moist  warmth  of  the  stomach, 


Fermentation  and  Digestion  23 

and  anything  which  checks  the  former  tends  to  encourage 
the  latter ;  hence  food  matters  which  are  not  readily 
permeated  and  broken  down  by  the  gastric  juice,  dilution 
of  the  secretions  by  draughts  of  fluid  immediately  as- 
sociated with  eating,  fatigue,  worry,  or  sleep  on  a  full 
stomach,  are  all  likely  to  result  in  fermentation  getting 
ahead  of  digestion,  with  consequent  pyloric  spasm,  gastric 
dilatation,  hyperacidity  due  to  inorganic  acids,  and  the 
evolution  of  gas.  Such  a  meal  is  spoilt,  it  is  a  "  bad 
brew,"  and  the  sooner  it  is  got  rid  of  by  vomiting  or 
purging  the  better  for  the  individual.  These  are  nature's 
methods  of  cure  and  the  safest  and  speediest  to  imitate. 
Little  has  been  said  as  to  drug  treatment  in  connection 
with  this  occasional  disorder,  for  on  the  one  hand,  in 
otherwise  healthy  subjects,  the  rational  attention  to  diet 
and  the  physiology  of  digestion  should  suffice  to  prevent 
or  correct  such  errors,  and  on  the  other,  the  habit  of 
taking  the  numerous  nostrums  advocated  as  cures  for 
indigestion  has  led  to  Uttle  good  and  much  harm,  and  it 
is  not  contemplated  here  to  enter  into  a  consideration  of 
more  serious  forms  of  disease. 

There  are,  however,  some  preparations  which  afford 
reHef  to  the  temporary  discomfort.  Mention  has  already 
been  made  of  the  compound  rhubarb  pill,  which  may  be 
considered  the  most  wholesome  and  effective  remedy. 
Another  pill  is  composed  as  follows  : 

l^:.  Menthol gr.  J 

Calomel gr.  f 

Pulv.  Zingeribis       .        ,        .        .  gr.  ij 

Maltine q.s. 

This  affords  immediate  relief  to  flatulence  and  discom- 
fort and  tends  to  check  further  fermentation.  Three  or 
four  may  be  taken  at  intervals  of  a  quarter  of  an  hour. 
Rather  less  efficient  in  their  effects  are  the  bismuth 
and  soda  lozenges  of  the  British  Pharmacopoeia.  The 
Mistura    Bismuthi    Co,    recommended    by    the    British 


24  Constipation 

Pharmaceutical  Congress  ^  is  an  agreeable  and  soothing 
compound,  but  belongs  to  a  more  serious  class  of 
remedies,  containing  as  it  does  morphine  and  hydro- 
cyanic acid. 

Constipation. — Among  minor  disorders,  it  would  be 
difficult  to  select  one  which  is  so  prevalent,  productive 
of  so  many  complications  and  remote  disturbances,  so 
difficult  to  remedy  in  its  later  stages,  and  which  is  so 
neglected  in  its  beginning  when  the  obstacles  to  recovery 
are  slight.  The  periodical  evacuation  of  the  residue  of 
the  digestive  process  is  absolutely  essential  to  health  and 
comfort,  and  its  inefficient  performance  results  in  two 
groups  of  symptoms :  the  one  referable  to  mechanical 
distension  and  irritation,  both  local  and  reflex ;  the  other 
to  resorption  of  poisonous  matters  developed  or  surviving 
in  the  faeces. 

The  greater  part  of  the  large  intestine  is  principally 
concerned  with  the  absorption  of  the  chyme  poured  into 
the  ascending  part  by  the  ileum,  and  its  contents  gradually 
pass  from  liquid  to  solid  as  they  approach  the  rectum,  the 
numerous  pouches  tending  to  delay  the  transit  and  increase 
the  surface  for  absorption,  which  is  normally  not  complete 
till  this  last  part  of  the  intestine  is  reached,  and  the  usual 
amount  of  the  daily  evacuation,  some  five  or  six  ounces, 
is  no  more  than  the  rectum  can  easily  accommodate. 

Compared  with  the  rest  of  the  large  intestine,  the 
rectum  is  straight,  smoothly  cylindrical  and  thick-waUed, 
adapted  to  the  modelling  and  expulsion  of  the  final 
residue  of  the  food,  which  comes  to  rest  at  the  internal 
sphincter  and  accumulates  for  a  distance  above  this, 
according  to  the  infrequency  with  which  the  bowel  is 
emptied.  This  wait  in  close  proximity  to  a  ring  of  lym- 
phoid tissue  is  closely  associated  with  local  infections 

'  Morphine  Hydrochloride  8  2:r.,  Distilled  Water  4  3,  Compound  Tincture 
of  Cardamoms  3  §,  Chloroform  70  vii,  Liq.  Extract  of  Nux  Vomica  135  m, 
Acid.  Hydrocyan.  dil.  820  ni ;  mix  and  add  concentrated  solution  of 
Bismuth  15  §,  and  water  q.s.  to  one  pint.    Dose  20-30  tn,. 


Causes  and  Consequences  25 

resulting  in  ischio-rectal  abscess,  fistula,  proctitis,  and 
possibly  haemorrhoids. 

The  immediate  result  of  omitting  to  empty  the 
rectum,  a  matter  which  is  under  the  control  of  the  will, 
is  the  accumulation  of  faecal  matter  involving  distension 
of  this  portion  of  the  gut  till  it  encloses  a  globular  mass 
instead  of  a  tapering  cylinder,  the  ejection  of  which 
through  the  small  though  distensible  anal  orifice  becomes 
increasingly  difficult.  In  addition,  the  walls  of  the 
rectum,  thinning  as  they  distend,  lose  power  of  con- 
traction, and  the  contained  matter  by  continuous  ab- 
sorption of  fluid  becomes  harder,  while  the  concentration 
causes  the  phosphate  of  lime  to  deposit  in  rough  mortar- 
like masses  of  crystals.  Fortunately,  at  first,  increasing 
distension  of  the  rectum  excites  contraction  which  is  at 
last  irresistible,  but  by  habitual  retention  this  tolerance 
is  encouraged,  the  muscular  walls  cease  to  respond,  and 
particularly  as  age  advances,  what  is  termed  "  ballooning 
of  the  rectum,"  with  deficient  contractility,  supervenes, 
and  habitual  constipation  is  established.  The  evils 
which  ensue  are  :  constant  and  increasing  difficulty  in 
emptying  the  bowels,  serious  complications  from  straining 
at  stool,  fsecal  obstruction  and  stercoral  ulcers,  which 
may  perforate. 

Other  causes  which  tend  to  difficulty  in  relieving  the 
bowels  are :  taking  too  little  fluid,  so  that,  the  needs  of 
the  economy  being  stinted,  absorption  by  the  colon  is 
carried  on  to  almost  complete  dryness  of  its  contents ; 
taking  little  food,  and  that  of  a  nature  to  leave  scanty 
residue ;  inactivity,  which  results  in  loss  of  muscular  power 
in  the  abdomen  and  probably  defective  bile  secretion ; 
and  the  ingestion  of  astringents,  such  as  lead,  hard 
water,  or  tea  which  contains  much  tannin. 

Exceptional  causes  are  surgical  operations  about  the 
perineum,  paralysis  of  the  diaphragm  or  abdominal 
muscles,   and   other  conditions   affecting   the   power   of 


26  Remote  Effects  of  Constipation 

compressing  the  abdomen.  I  have  known  a  case  of 
extreme  emphysema  where  great  difficulty  existed  in 
this  respect,  and  it  should  never  be  forgotten  that  dis- 
placements or  tumours  in  the  pelvis  or  actual  stricture 
of  the  lower  bowel  may  for  a  long  time  convey  no  other 
impression  to  the  patient  than  difficulty  in  defsecation. 

The  common  effects  of  constipation  are  headache, 
loss  of  appetite,  foul  breath,  and  furred  tongue.  There 
is  often  irritability  of  temper,  lack  of  power  of  applica- 
tion, and  general  malaise.  Inability  to  sleep  soundly 
and  waking  unrefreshed  are  common  accompaniments, 
usually  associated  with  increased  vascular  tension. 
Among  special  disturbances  may  be  mentioned  epistaxis, 
and  such  paroxysmal  affections  as  asthma,  migraine, 
bilious  attacks,  and,  in  children,  convulsions.  Epileptic 
fits  are  encouraged,  but  can  hardly  be  said  to  originate 
in  constipation. 

There  are,  moreover,  many  complex  and  irregular 
groups  of  symptoms  which  might  not  ordinarily  be 
thought  of  in  this  connection,  due  nevertheless  to  what 
has  been  termed  Copraemia,  or  toxic  absorption  from 
the  colon.  Such  cases  are  often  rendered  all  the  more 
difficult  of  detection  by  the  faecal  accumulation  being 
masked  by  even  a  daily  motion  of  the  bowels,  and  it 
may  be  only  by  a  pelvic  examination  or  the  recog- 
nition of  scybala  by  palpating  the  abdomen  that  a 
knowledge  of  the  true  state  of  things  is  arrived  at. 
Complete  corroboration  is  subsequently  afforded  by  the 
immediate  recovery  of  the  patient  when  effective  purga- 
tive measures  have  been  adopted. 

For  instance,  a  woman  of  thirty-five  had  been  ill  for 
five  weeks  with  an  eruption  of  erythema  multiforme,  the 
temperature  rising  to  103°  every  other  day  with  chills 
and  sweats  as  in  malaria,  the  bowels  were  recorded  as 
acting  daily,  yet  a  pelvic  examination  undertaken  in  the 
expectation  of  finding  some  source  of  septic  infection, 


Remote  Effects  of  Constipation  27 

which  had  been  excluded  elsewhere,  revealed  only  a 
loaded  rectum,  and  the  adoption  of  thorough  evacuant 
measures  practically  disposed  of  all  symptoms  in  twenty- 
four  hours.  Another  young  woman  had  been  invahded 
for  a  similar  term  with  continual  rejection  of  food  and 
recurring  hsematemesis  associated  with  anaemia  and 
remarkable  fractiousness,  reHeved  for  a  time  by  careful 
dieting,  but  presenting  aU  the  features,  including  epi- 
gastric tenderness,  of  relapsing  gastric  ulcer.  This  case 
made  no  real  progress  till  resolute  purgation  was  adopted, 
though  the  bowels  had  been  apparently  acting  regularly, 
and  then  she  recovered  at  once. 

Instances  of  severe  neuralgic  headache,  palpitation, 
bronchial  asthma,  and  pains  referred  to  the  muscles  or 
fasciae,  or  called  lumbago  and  sciatica,  are  of  frequent 
occurrence,  and  often  yield  at  once  to  an  enema  or  purga- 
tive. The  older  generation  of  practitioners  had  a  higher 
appreciation  of  the  value  of  keeping  the  bowels  open  than 
we  have  now,  just  as  they  paid  more  attention  to  the 
characters  of  the  pulse  and  tongue. 

Habitual  constipation  may  often  be  remedied  by 
diet  with  only  the  occasional  employment  of  drugs, 
and  to  arrange  this  efiectually  the  physiology  of  the 
colon  must  be  principally  considered,  the  factors  of 
most  importance  being  habit,  moisture  and  bulk  of 
residual  matter,  and  the  due  activity  of  the  muscles  and 
glands  concerned. 

The  evidence  of  rhythm  in  the  bodily  economy  is  so 
obvious  that  it  is  hardly  necessary  to  refer  to  it.  The 
disposition  to  sleep,  to  wake,  and  to  take  food  recurs  in 
most  individuals  with  the  regularity  of  the  clock,  and 
this  periodicity  is  marked  in  disease,  by  the  recurrence 
of  paroxysms  such  as  those  of  ague,  asthma,  neuralgia, 
exacerbations  of  fever,  and  many  neurotic  seizures  at 
one  particular  hour.  A  similar  cycle  is  observable  in 
the  majority  of  healthy  people  in  connection  with  the 


28  Influence  of  Habit 

bowels,  and  should  be  imitated  by  those  who  aspire  to  a 
similar  satisfactory  condition.  There  is  in  addition  a  re- 
markable sympathy  between  the  stomach  and  the  colon, 
shown  in  many  ways,  but  particularly  in  the  tendency  of 
the  ingestion  of  food  to  excite  activity  in  the  lower  bowel. 
In  some  diseases  and  nervous  conditions,  as  well  as  under 
the  influence  of  strychnine,  this  is  so  irresistible  that  every 
meal  is  interrupted  by  the  necessity  for  going  to  stool. 

It  is  probably  owing  to  this  as  well  as  convenience 
that  the  usual  time  allotted  to  this  necessary  function 
is  shortly  after  breakfast,  and  such  a  salutary  habit  should 
be  seriously  insisted  on  as  a  primary  feature  in  correcting 
constipation.  In  many  cases  it  will  be  found  that  a 
departure  from  this  for  one  reason  or  another  has  marked 
the  commencement  of  the  complaint. 

As  has  been  already  mentioned,  the  habit  of  drinking 
an  insufficient  quantity  of  fluid  has  a  tendency  to  induce 
constipation  by  rendering  the  excreta  too  dry  and  hard, 
as  in  the  condition  of  fever.  Perhaps  the  facilities  of 
modern  life  have  diminished  the  necessity  for  physical 
exertion,  so  that  those  who  are  exempt  from  labour  and 
not  addicted  to  athletics  have  not  much  real  inducement 
to  thirst ;  but  in  addition  to  this,  the  inconvenience  of 
normal  activity  of  the  skin  and  kidneys  in  the  course  of 
prolonged  amusements,  social  functions,  and  journeyings 
sometimes  prompts  women  more  especially  to  limit  the 
quantity  of  fluid  taken.  This  is  an  unwholesome  practice, 
which,  in  addition  to  the  result  here  indicated,  leads  to 
too  great  a  concentration  of  the  natural  fluids  of  the 
body,  and  may  scarcely  aUow  some  of  the  less  soluble 
salts  to  remain  in  solution. 

The  amount  of  fluid  dafly  required  by  the  body  is 
two  pints  or  more.  The  kidneys  should  remove  forty 
ounces  and  the  lungs  account  for  about  the  same  quantity 
in  aqueous  vapour,  though  this  may  be  supplied  by 
the  food,   which   may  be   considered   to   consist  of   50 


Adjuvants  29 

per  cent,  water.  There  still  remain  losses  to  be 
accounted  for  by  the  skin  and  bowels,  so  that  an  allowance 
of  two  pints  of  fluid  a  day  is  really  a  very  small  one, 
and  yet  many  people,  especially  women,  do  not  take 
the  equivalent  of  five  tumblerfuls  in  the  twenty-four 
hours,  -which  constitutes   this   amount. 

The  dejecta  consist  of  the  undigested  and  indiges- 
tible portions  of  the  food  taken  and  the  residues  of 
the  digestive  secretions,  with  more  or  less  poisonous 
matter  returned  from  the  liver  in  the  bile,  and  the 
various  micro-organisms  which  flourish  in  the  intes- 
tinal tract.  Their  bulk  necessarily  varies  with  the 
quantity  and  degree  of  solubility  of  the  food.  Though 
absolute  abstention  does  not  completely  abolish  them, 
as  may  be  seen  in  starvation  and  in  newly  born 
infants,  yet  it  has  an  important  influence  on  the 
frequency  and  ease  with  which  the  rectum  empties  itself. 
The  addition  of  such  indigestible  matter  as  the  seeds 
and  skins  of  fruits,  some  of  the  husk  of  wheat,  as  in 
brown  or  wholemeal  bread,  and  the  cellulose  structure 
of  vegetables,  with  whatever  else  that  is  unirritating  and 
sufficiently  comminuted  to  readily  pass  the  pylorus,  must 
be  regarded  as  wholesome  in  assisting  the  regular  action 
of  the  bowels.  The  effect  of  subsisting  entirely  on 
elaborately  selected  and  prepared  food,  including  fine 
white  bread,  from  which  these  coarser  elements  are  ex- 
cluded, is  entirely  the  opposite. 

The  influence  of  muscular  and  glandular  activity  in 
assisting  the  action  of  the  bowels  is  best  fllustrated  by 
the  common  experience  of  the  effects  of  sedentary  habits, 
of  the  exclusion  of  bile  from  the  intestine  in  obstructive 
jaundice,  and  the  indirect  effect  of  extremes  of  heat 
and  cold,  in  inducing  constipation. 

From  these  observations  it  will  be  understood  that 
the  natural  remedy  for  constipation  consists  in  affording 
regular    opportunity    for    the    bowels    to    act    and    so 


30  Remedies 

cultivating  the  habit ;  taking  sufficient  fluid  to  satisfy  all 
the  needs  of  the  body  without  carrying  the  desiccation  of 
the  bowel  contents  too  far  (a  glass  of  water  night  and 
morning  being  a  useful  addition  to  the  usual  daily  con- 
sumption), taking  a  due  proportion  of  indigestible  matter 
in  a  divided  form,  such  as  is  contained  in  brown  bread, 
marmalade,  oatmeal,  and  fresh  or  dried  fruits,  with  such 
ordinary  laxatives  as  syrup,  honey,  preserves,  and  salad 
oil.  The  question  of  exercise  must  be  suited  to  the  age 
and  circumstances  of  the  individual,  but  is  most  effective 
when  taken  before  breakfast,  if  only  as  gymnastic  move- 
ments which  include  the  abdominal  muscles.  It  may 
be  considered  that  no  exercise  is  worthy  the  name  which 
does  not  quicken  the  pulse  and  respiration  and  so  far  in- 
crease the  development  of   heat  as  to  moisten  the  skin. 

Where  these  measures  prove  insufficient  recourse 
must  be  had  to  drugs,  not  more  than  two  days  being 
allowed  to  pass  without  an  action.  The  mildest  laxa- 
tives that  are  efficient  should  be  adopted,  as  the  more 
powerful  the  drug  the  greater  the  reaction,  and  constipa- 
tion is  relieved  not  cured  by  purgatives.  The  confections 
of  sulphur  or  senna,  manna,  castor  oil  in  doses  of  a 
drachm  or  two  well  shaken  with  milk,  or  sulphate  of 
magnesium  or  sodium  in  drachm  doses  with  half  a  pint  of 
water  should  be  taken  in  the  early  morning,  and  are  mild 
enough  to  be  given  to  children.  Calomel  as  lozenges 
containing  one-eighth  or  one-tenth  of  a  grain,  Colalin  in 
half -grain  tablets,  or  small  doses  of  Cascara  may  be  taken 
three  times  a  day.  A  useful  pill  is  that  recommended  by 
the  late  Sir  Andrew  Clark  containing  a  quarter  of  a  grain 
each  of  calomel,  euonymin,  iridin,  and  podophyllin,  which 
should  be  taken  at  night ;  the  latter  drug  is  sometimes 
effective  alone,  one  grain  being  dissolved  in  an  ounce  of 
glycerine  and  teaspoonful  doses  taken  at  intervals  of 
four  hours. 

These  may  be  regarded  as  adjuvants  to  the  regime 


Cracked  Lip  31 

already  recommended,  but  where  accumulation  has  al- 
ready taken  place  the  bowel  must  be  cleared  by  means 
of  enemata  either  of  soap  and  water  alone,  or  if  induration 
has  already  taken  place,  this  should  be  preceded  by  a 
drachm  or  two  of  glycerine  or  five  ounces  of  olive  oil. 
A  sufficient  dose  of  castor  oil  should  also  be  given  to 
complete  evacuation  of  the  higher  reaches  of  the  intestine. 
In  spite  of  the  most  active  purgation  hard  scybala  con- 
verted almost  to  the  consistence  of  stones  by  phosphate 
of  lime  may  remain  in  the  pouches  of  the  colon,  easily 
palpable  through  the  abdominal  wall  and  merely  tun- 
nelled or  grooved  by  the  passage  of  more  fluid  matter. 
These  can  scarcely  be  removed  except  by  croton  oil, 
not  given  in  such  drastic  doses  as  one  minim,  but  in 
one-sixth  or  one-third  of  a  grain  repeated  three  times 
a  day,  either  in  a  pill  containing  some  carminative  or 
with  half  an  ounce  of  castor  oil  flavoured  with  pepper- 
mint or  menthol.  Croton  oil  is  not  an  agreeable  remedy 
for  the  patient  and  requires  great  care  in  its  administration 
by  the  practitioner,  but  there  appears  to  be  no  other 
drug  which  excites  sufficient  secretion  and  peristalsis  to 
dislodge  these  concretions,  which  seem  almost  embedded 
in  the  mucous  membrane.  All  the  more  care  is  needed 
since  they  chiefly  occur  in  elderly  and  feeble  individuals. 
If  there  is  any  doubt  as  to  their  presence  either  before  or 
after  attempts  at  treatment,  it  can  easily  be  dispelled 
by  an  X-ray  skiagram. 

Craeked  Lip, — It  is  well  known  that  eczema  is 
specially  prone  to  occur  at  the  junction  of  mucous 
membrane  and  skin,  and  this  petty  lesion  is  a  case  in 
point.  Either  upper  or  lower  lip  may  be  affected,  usually 
in  the  middle  line,  the  next  point  of  election  being  the 
corner  of  the  mouth.  Owing  to  the  mobility  of  the 
part  and  its  peculiar  sensitiveness,  even  a  trifling  fissure 
constantly  asserts  itself,  is  slow  to  heal,  bleeds  readily, 
and   proves   a   great   source   of   discomfort.     It   occurs 


32  Local  Measures 

mostly  in  spring  and  autumn  and  in  association  with 
catarrh  or  disturbance  of  digestive  function.  Once 
developed,  it  may  persist  or  recur  for  several  days,  but 
does  not  penetrate  below  the  surface  of  the  cutis  and  is 
very  rarely  multiple.  The  best  local  application,  more 
effective  at  night,  is  an  ointment  composed  of  fifteen 
grains  of  lead  acetate  to  an  ounce  of  white  vaseline  or 
lard.     But  lotions  such  as  Hebra's — 


^.  Carbolic  Acid        .        .         .        ,        .39 

Glycerine gj 

Ether gj 

Spir.  Vin.  Eect g  vj 


or  a  simple  solution  of  2-10  grains  of  Silver  Nitrate  in 
Nitrous  Ether  5  j,  are  serviceable  and  more  convenient  by 
day.  Intractable  fissures  may  be  touched  with  sulphate 
of  copper  or  lunar  caustic,  after  moistening  the  hard  edge, 
at  night.  A  small  dose  of  calomel  or  blue  pill  followed 
by  a  saline  purge  is  often  of  service  in  connection  with 
associated  digestive  disturbance. 

A  more  diffuse  dry  eczema  causing  roughening  and 
soreness  at  the  edge  of  the  lip  and  in  patches  around  the 
mouth,  particularly  in  children  and  those  with  thin 
clear  skin,  during  the  prevalence  of  dry  east  wind  and 
cold  weather,  may  be  relieved  with  any  simple  ointment, 
but  the  dilute  white  precipitate  ointment  or  the  glycerine 
of  tannic  acid  with  an  equal  quantity  of  eau  de  Cologne 
is  particularly  suitable. 

Catapphal  Herpes. — In  the  immediate  vicinity  of 
the  several  orifices  of  the  body  there  not  infrequently  occurs 
an  outcrop  of  small  vesicles  on  a  reddened  base  preceded  by 
papules  and  attended  by  a  sensation  of  heat  and  tension. 
Such  outbreaks  are  usually  noticed  about  the  mouth, 
nostrils,  and  meatus  urinarius,  more  rarely  near  the 
eye,  external  auditory  meatus  or  anus.  The  eruption 
may  even    attack  the  mucous  membrane  in  the  con- 


Catarrhal  Herpes  :i3 

junctival  sac,  buccal  cavity,  fauces,  and  urethra  or  im- 
mediate neighbourhood.  Though  it  resembles  shingles 
in  appearance,  it  differs  in  its  tendency  to  recur,  affecting 
the  same  individual  in  some  cases  every  few  months, 
and  in  the  absence  of  neuralgic  pain. 

The  onset  is  often  marked  by  chilliness  or  actual 
shivering  with  slight  rise  of  temperature,  and,  on  the 
face  especially,  it  is  a  frequent  accompaniment  of  various 
specific  fevers,  particularly  coryza,  pneumonia,  and  ague. 
It  sometimes  occurs  endemically,  possibly  in  connection 
with  defective  hygiene,  outbreaks  being  reported  from 
time  to  time  as  "  herpetic  fever." 

The  attack  itself  is  of  little  importance  apart  from 
its  symptomatic  association,  but  is  productive  of  some 
soreness  and  disfigurement  at  the  time,  and  sometimes 
gives  rise  to  anxiety  when  affecting  the  genitalia  through 
being  mistaken  for  venereal  disease. 

The  treatment  consists  in  protecting  the  vesicles  from 
the  air  and  drying  them  by  starch  and  zinc  powder  : 
an  ointment  of  zinc  oxide  or  boracic  acid  being  a 
soothing  application  if  the  patient  is  not  going  about. 

When  affecting  moist  surfaces,  frequent  washing  and 
the  separation  of  contiguous  parts  with  lint  soaked  in 
weak  boracic  acid  or  lead  lotion  are  more  suitable.  In 
the  mouth  and  conjunctiva  gargles  and  collyria  can  alone 
be  used.  On  the  genitals  if  superficial  suppuration 
occurs,  although  this  is  somewhat  exceptional,  aristol 
powder  may  be  employed  or  lint  soaked  in  a  weak 
solution  of  peroxide  of  hydrogen. 

In  regard  to  recurrence  the  only  preventive  measures 
are  daily  washing  of  any  part  particularly  liable  to  attack, 
and  the  special  consideration  of  any  diathetic  state  that 
predisposes,  the  most  important  of  which  is  gout.  The 
arrest  of  local  chronic  or  recurring  discharge  in  the  threa- 
tened area  should  not  be  neglected. 

Dpy  Mouth. — The  persistent  deficiency  of  secretion 

3 


34  Dry  Mouth 

in  the  mucous  membrane  of  the  mouth  and  of  the  salivary 
glands,  though  consistent  with  good  general  health,  is 
productive  of  serious  discomfort,  the  movements  of  the 
tongue  and  lips  being  so  far  interfered  with  that  talking 
and  eating  become  almost  impossible  without  continually 
sippiQg  fluid. 

Some  half  a  dozen  instances  of  this  distressing  affection 
have  been  brought  to  the  notice  of  the  profession  by 
Mr.  Hutchinson  and  the  late  Dr.  Hadden,  but  doubtless 
many  others  have  existed,  and  as  a  temporary  condition 
it  is  probably  more  common.  It  has  been  regarded  as  a 
neurosis  of  the  sympathetic,  having  in  one  case  at  least 
followed  mental  shock  and  been  associated  with  sup- 
pression of  lachrjmaal  secretion  either  on  emotional  or 
reflex  excitation.  Mr.  Hutchinson  has  suggested  that 
it  is  allied  to  the  physiological  state  of  fear  or  nervous 
excitement  in  which  the  buccal  secretions  are  commonly 
suppressed. 

In  the  cases  described,  the  lining  of  the  mouth  and 
tongue  was  much  altered,  becoming  smooth  and  shining 
with  impairment  of  taste  and  diminution  of  sensibility, 
the  tongue  itself  becoming  fissured,  very  red,  and  quite 
denuded  of  papillae. 

As  a  concomitant  of  fever,  particularly  when  accom- 
panied by  nervous  prostration,  desiccation  of  the  mouth  is 
familiar  enough,  as  it  is  also  in  severe  cases  of  diabetes,  and 
the  same  thing  is  observed  in  some  cases  of  neurasthenia. 
So  far  all  the  idiopathic  cases  reported  have  been  in  women 
of  from  fifty  years  upwards.  Treatment  in  these  has  so 
far  been  unsatisfactory,  the  use  of  glycerine  locally  and 
tincture  of  jaborandi  in  vf[^  xxx  doses  three  times  a  day 
affording  only  very  partial  alleviation.  In  the  sympto- 
matic cases  benefit  has  resulted  from  the  administration 
of  lemon  juice,  dilute  phosphoric  acid,  pyrethrum  and 
pilocarpine,  the  latter  in  the  form  of  tablets  (gr.  1/10). 

Uleep    of  the    Tong-ue    and    Mouth.— The 


Ulcers  of  Mouth  35 

irritable  ulcer  at  the  side  of  the  tongue  commonly  situated 
about  the  middle,  and  rather  towards  the  upper  than  the 
lower  surface,  is  practically  always  due  to  contact  with  a 
projecting  point,  such  as  a  collection  of  tartar  or  a  broken 
tooth.  Swelling  of  the  tongue  is  an  important  factor  in 
the  trouble.  Variations  in  the  bulk  of  the  organ  are  very 
wide,  as  may  be  seen  in  comparing  the  thin  dry  tongue 
of  fever  or  of  irritant  dyspepsia  with  the  pale  swollen 
teeth-indented  tongue  of  atonic  dyspepsia.  The  pro- 
jection from  the  tooth  may  indeed  be  persistent,  perhaps 
a  natural  cusp,  and  yet  ulcer  and  soreness  occur  in  the 
same  spot  only  at  intervals,  generally  opposite  a  bicuspid. 
This  results  from  the  enlargement  of  the  tongue  often  in 
association  with  atonic  dyspepsia,  causing  it  to  bulge 
against  the  teeth,  the  indentations  being  obvious  along  its 
edges.  For  some  time,  though  soreness  is  felt,  no  definite 
lesion  can  be  seen,  then  there  appears  some  redness  and 
irregularity  of  surface,  and  finally  a  shallow  soft  ulcer, 
the  trouble  in  one  phase  or  another  lasting  days  or 
even  weeks,  sometimes  with  remissions  or  recurrences. 

Treatment  consists  in  removing  any  sharp  projection 
from  the  tooth,  and  in  reducing  the  bulk  of  the  tongue, 
which  can  be  best  accomplished  by  purgatives  and  a 
mixture  of  mineral  acid  and  strychnine.  Some  relief 
may  be  afforded  in  the  meantime  by  the  use  of  lozenges 
of  cocaine,  borax,  and  chlorate  of  potash,  and  healing 
may  be  hastened  by  applying  sulphate  of  copper  in  crystal 
to  the  surface,  or  by  ordering  the  patient  to  frequently 
paint  the  surface  of  the  sore  with  a  solution  of  chromic 
acid  (gr.  X  to  water  5  ])• 

This  treatment  is  only  applicable  to  the  soft,  super- 
ficial, and  transient  abrasions.  An  ulcer  with  definite 
edge  or  indurated  base  may  be  tuberculous,  syphilitic, 
or  cancerous,  and  requires  very  serious  consideration. 

Dyspeptic  ulcers  occur  in  the  front  of  the  mouth 
either  towards  the  tip  of  the  tongue  or  on  the  adjacent 


36 


Oral  Antisepsis 


mucous  membrane  beneath  it  or  inside  the  under-lip. 
One  or  more  points  may  be  affected,  each  ulcer  appearing 
as  a  buff  more  or  less  circular  or  oval  patch  surrounded 
by  a  narrow  red  margin.  The  ulcers  are  painful,  smarting 
especially  when  food  is  taken,  and  commonly  last  several 
days.  They  are  usually  associated  with  gastric  disturb- 
ance, either  catarrh  or  dyspepsia,  and  require  both  local 
and  general  treatment.  After  drying  the  surface,  lunar 
caustic  may  be  lightly  applied  or  the  crystal  of  copper 
sulphate  held  in  contact  for  a  minute,  till  the  buff  surface 
is  destroyed  and  sufficient  reaction  excited  to  encourage 
healing.  The  ulcers  often  commence  in  small  cystlike 
developments  of  the  mucous  glands,  and  are  commonly 
associated  with  an  acid  reaction  of  the  secretions  of  the 
mouth,  so  that  an  alkaline  mouth  wash  or  antacid  tooth 
powder  is  beneficial.  A  very  useful  mouth  wash  in 
ulcerative  or  septic  conditions  of  the  mouth  is  composed 
as  follows  : 


Thymol    . 

.        .        .    gr.j 

Acid.  Benzoic  .        , 

•    gr.j 

01.  Gaultherii.         . 

.      .      .     mj 

Eucalyptol      .        , 

.     mi 

01.  Menth.  Pip. 

.      .      .     ml 

Spir.  Vin.  Eect, 

.       .       .       3j 

Acid.  Boric.    .        .        , 

gr.  XXV 

Glycerin!         ,     ,   . 

.       .       .       3J 

Tr.  Cocci 

.  m  XX 

Aq.  dest. 

.  ad  0.  j 

A  preparation  similar  to  Odol  is  produced  by  dissolving 
Salol  2-5,  Saccharin  -004,  Peppermint  Oil  -5  in  Alcohol 
80  per  cent.  97,  and  adding  Clove  and  Caraway  Oils. 

The  general  treatment  should  consist  of  mineral  acid 
and  some  vegetable  bitter  with  a  laxative.  A  compound 
rhubarb  pill  taken  for  two  or  three  days  before  the 
evening  meal  is  effectual,  and  small  doses  of  strychnine 
with  nitrohydrochloric  acid  and  sulphate  of  soda  or 
magnesia  answer  very  well. 


Pyorrhoea  Alveolaris  37 

When  the  mouth  affection  is  very  diffuse,  as  in  ulcera- 
tive stomatitis,  aphthous  stomatitis  and  gingivitis, 
local  measures  should  be  restricted  to  the  use  of  the 
mouth  wash  or  glycerine  of  borax  at  frequent  intervals, 
the  caustic  being  omitted. 

Sometimes  after  taking  strong  cheese  and  other 
irritating  condiments,  there  develops  a  follicular  inflam- 
mation over  the  hard  palate  for  an  inch  or  so  behind  the 
incisor  teeth  persisting  for  several  days,  but  which  is 
speedily  relieved  by  the  mouth  wash  above  mentioned. 

As  a  preventive  measure,  now  that  oral  sepsis  is  re- 
cognised as  the  source  of  both  local  and  general  disease, 
the  employment  at  least  once  a  day  of  an  antiseptic 
mouth  wash  containing  permanganate  of  potash  or 
dilute  formalin,  such  as  the  preparation  known  as  "  For- 
molyptol,"  is  to  be  strongly  recommended,  as  a  preserva- 
tive both  of  the  teeth  and  the  health,  and  as  a  preventive 
of  many  minor  disorders  of  the  mouth  and  throat. 

Rig-g-s's  OP  Fauehapd's  Disease  (Pyopphcea 
Alveolapis). — Though  anything  but  a  recent  discovery 
in  medicine,  modern  conservative  dentistry  and  the  recog- 
nition of  oral  sepsis  as  a  fertile  source  of  chronic  disturb- 
ance of  health  have  led  to  a  wide  expansion  of  interest  in 
this  complaint.  As  it  is,  moreover,  a  very  common  one, 
insidious  in  onset  and  not  invariably  painfully  assertive, 
it  is  either  overlooked  by  patients  or  not  thought  worthy 
of  mention  to  the  medical  attendant,  though  it  may  be 
the  underlying  source  of  more  definitely  recognised  dis- 
orders. The  etiology  of  the  complaint  is  not  absolutely 
clear :  rheumatism  has  been  suggested,  and  in  this  country 
at  least,  few  can  claim  to  have  been  wholly  free  from  any 
taint  of  that  widespread  affection.  Inefficient  brushing 
of  the  teeth  allowing  formation  of  tartar  between  them 
and  the  gums,  and  the  known  profusion  of  micro-organisms 
existing  in  the  mouth,  offer  more  reasonable  explana- 
tions.    Once  established  in  such  inaccessible  fissures,  the 


38  Pyorrhoea  Alveolaris 

cocci  are  free  to  develop  and  extend  unchecked,  and  to 
run  the  gauntlet  of  the  digestive  tract :  perhaps  sometimes 
in  disordered  states  of  the  secretions  escaping  destruc- 
tion and  obtaining  a  lodgment  elsewhere,  as  in  the 
stomach  or  appendix  vermiformis.  Locally,  various 
septic  and  suppurative  lesions  of  the  buccal  mucous 
membrane,  teeth,  and  tonsils,  recurring  at  intervals,  are 
traceable  to  the  affection. 

Souwers  in  TTie  New  York  and  Philadelphia  Medical 
Journal  for  July  30,  1904,  writes  :  "  Recurring  tenderness 
of  the  teeth,  making  mastication  uncomfortable,  accom- 
panied by  some  soreness  of  the  gums,  is  frequently  re- 
ferred to  the  catching  of  slight  colds,  or  to  the  stomach 
being  out  of  order.  The  first  reason  for  taking  advice  is 
often  that  the  individual  has  noticed  the  receding  of  the 
gums  from  certain  teeth,  or  that  the  use  of  the  tooth- 
brush, or  even  slight  pressure  by  the  fingers,  occasions 
bleeding.  The  occurrence  of  pain,  resembling  in  character 
that  experienced  when  exposed  dental  nerves  are  sub- 
jected to  varying  temperatures  on  taking  food  or  drink, 
but  situated  at  the  lateral  surfaces  of  the  teeth,  will  forcibly 
notify  the  sufferer  that  action  of  some  kind  is  essential. 
Even  sudden  changes  in  atmospheric  temperature,  as  in 
going  from  a  warm  room  into  a  cold  entry,  the  mouth  being 
open,  will  start  an  attack  of  aching.  In  other  cases  there 
is  a  sensation  of  burning  and  stinging  situated  along  the 
gingival  border  in  the  upper  jaw,  the  feeling  being  par- 
ticularly marked  in  the  rugse  behind  the  incisors.  On 
examination  the  mucous  membrane  is  found  red,  shining, 
swollen,  and  appears  to  hang  in  folds  ;  and  to  the  patient, 
when  impact  is  made  by  the  tongue,  this  suggests  that  pus 
or  fiuid  of  some  kind  must  be  present.  When  touched 
by  the  finger,  the  feeling  of  a  sodden  tissue  is  given. 
Slight  pressure  over  the  diseased  area,  when  the  trouble 
has  progressed  sufficiently,  will  elicit  a  slight  purulent 
discharge  in  even  very  mild  cases.     In  those  mouths  in 


Treatment  39 

which  the  morbid  condition  has  been  long  continued, 
there  will  be  found,  between  the  gums  and  teeth,  varying 
quantities  of  tartar,  which,  by  constant  accretions,  act 
as  a  wedge  that  slowly  but  surely  causes  a  recession  of 
the  gum,  the  ultimate  result  being  the  loosening  and 
dropping  out  of  the  teeth.  Even  in  mild  recent  attacks, 
where  prompt  treatment  has  caused  a  halt  of  the  invader, 
examination  of  the  tooth  fangs,  by  means  of  a  small 
scaler  introduced  between  the  neck  of  the  tooth  and  the 
gum,  will  generally  reveal  commencing  deposits,  the 
presence  of  which  is  resented  by  the  gum,  as  shown  by 
its  tenderness,  sponginess,  and  bulging  between  the  teeth, 
its  tendency  to  ooze  blood,  and  the  constantly  recurring 
gumboils  which  make  life  a  burden  to  the  sufferer." 

The  prognosis  was  at  one  time  regarded  as  extremely 
unfavourable,  but  under  decided,  persistent,  and  patient 
treatment  a  cure  may  be  effected,  though  relapse  will 
follow  neglect,  or  the  too  early  cessation  of  treatment. 

The  treatment  consists  first  in  remedying  any  systemic 
diathesis,  such  as  gout  or  rheumatism,  and  the  removal 
of  such  contaminating  influence  as  may  be  exercised  by 
painting  and  metal-working. 

Locally,  the  gums,  adjacent  rugae  on  the  palatal 
surface,  and  both  sides  of  the  teeth  must  be  thoroughly 
cleaned  with  hydrogen  peroxide,  taking  care  to  reach 
the  recesses  in  the  mucous  membrane  behind  the  last 
molar  teeth,  as  it  is  here  the  disease  lurks  when  all  other 
parts  have  apparently  returned  to  a  normal  condition. 
The  pus  having  been  thoroughly  removed  even  from  the 
fissures  between  the  teeth  and  gums  by  this  agent,  the 
mouth  must  be  well  rinsed  out  with  water.  Then,  on 
a  morsel  of  absorbent  wool,  aromatic  sulphuric  acid, 
either  pure  or  diluted  with  once  or  twice  its  bulk  of  water, 
according  to  the  severity  of  the  mischief,  is  applied, 
care  being  taken  that  all  recesses,  corners,  and  fistulous 
passages  are  searched  and  that  the  acid  is  applied  betwoei) 


40  Treatment 

the  gums  and  the  necks  of  the  teeth,  avoiding  as  far  as 
possible  touching  the  crowns.  The  pledget  of  wool  need 
not  be  dripping  with  acid  and  may  be  hardly  more  than 
thoroughly  damp.  Fine-pointed  forceps  must  be  used, 
as  the  application  should  be  effectually  inserted  between 
the  gum  and  the  teeth,  and  in  the  narrow  spaces  between 
adjacent  teeth.  For  reaching  into  a  sinus  too  small  to 
admit  the  pledget  of  wool,  applicators  made  of  paper  or 
Wood's  cotton  may  be  used. 

Following  the  acid,  a  mixture  of  equal  parts  of  sodium 
carbonate  and  borax  must  be  freely  applied,  being  well 
rubbed  in  either  with  a  piece  of  absorbent  cotton-wool  or 
with  the  finger,  taking  care  that  it  is  packed  firmly  into  the 
dental  interspaces,  so  as  to  completely  neutralise  the  acid. 

The  mouth  is  again  cleansed  by  water  ;  then  sulphate 
of  quinine  is  dusted  along  the  seat  of  disease  and  hghtly 
packed  between  the  teeth  ;  dipping  dry  absorbent  cotton 
in  the  quinine  and  lightly,  but  firmly,  dabbing  this  on 
the  diseased  parts  is  the  simplest  method. 

One  course  of  treatment  of  the  character  described 
will  often  suffice,  but  the  progress  of  the  case  will  indicate 
if  repetition  is  needed,  and  if  the  strength  of  the  acid 
should  be  modified. 

The  quinine  should  be  used  daily  till  the  gums  become 
and  remain  normal.  As  an  aid  in  the  relief  of  the  gum 
congestion,  a  solution  of  adrenalin  (1-1000)  is  effective, 
particularly  in  the  declining  stage  of  the  inflammation. 
The  patient  should  be  directed  to  use  a  mouth  wash  two 
or  three  times  daily  of  some  cleansing  antiseptic  prepara- 
tion. In  addition,  he  should  at  bedtime  rinse  the  mouth 
with  magnesia  cream  or  a  solution  of  magnesia,  leaving 
it  adhering  to  the  buccal  surface,  this  being  the  best 
preventive  of  tartar. 

Many  dentists  prefer  powdered  sulphate  of  copper  to 
the  aromatic  sulphuric  acid,  and  substitute  a  saturated 
solution  of  tannin  in  Eau  de  Cologne  for  the  quinine. 


Toothache  4^ 

Teeth  which  are  hopelessly  loosened  should  be  removed, 
this  being  the  readiest  means  of  curing  the  pyorrhoea. 

Where  the  teeth  are  sensitive  on  their  lateral  aspects 
to  changes  in  temperature,  protection  may  be  afforded 
by  drying  the  surface  and  applying  a  paste  made  of 
zinc  oxide  moistened  with  a  few  drops  of  phosphoric  acid, 
or  by  gently  swabbing  the  exposed  roots  of  the  teeth 
every  evening  with  alcohol. 

Toothaehe  (Odontalg'ia). — The  relief  of  pain  is 
essentially  the  province  of  medicine,  and  though  few- 
medical  men  extend  their  practice  into  the  realms  of 
dentistry,  there  are  occasions,  when  they  are  called  upon 
in  emergencies,  where  a  little  knowledge  and  resource 
may  save  a  great  deal  of  suffering,  and  only  such  occasions 
and  measures  will  be  adverted  to  here.  What  is  com- 
monly termed  "  toothache  "  may  be  either  odontalgia,  in 
which  pain  is  complained  of  in  a  tooth,  either  from 
local  disease  or  from  distal  nerve  disturbance,  or  else 
neuralgia  of  the  trigeminal,  which  in  many  cases,  though 
imperfectly  localised,  depends  on  dental  trouble. 

Sometimes  exposure  of  the  neck  or  fang  of  a  tooth 
from  retraction  of  the  gum,  when  associated  with  an 
acid  reaction  of  the  mouth  secretions,  gives  rise  to  pain. 
Under  similar  circumstances  a  carious  tooth  of  old 
standing  may  cause  suffering.  It  is  useful,  therefore, 
to  remember  that  merely  rinsing  the  mouth  with  a  little 
warm  water  and  soda  or  sal  volatile  will  in  such  instances 
give  relief. 

The  main  causes  of  pain,  however,  of  a  more  severe 
type  are  inflammation  of  the  pulp  or  periosteum,  the 
one  involving  caries,  and  the  other  redness  and  swelling 
of  the  gum,  in  either  case  tenderness  on  pressure  being 
a  prominent  symptom.  In  rarer  instances  the  pain  is  as- 
sociated with  retrogressive  changes  in  the  pulp  or  nerve 
of  an  apparently  sound  tooth  or  one  that  has  been  filled. 

Acute  inflammation  of  the  pulp  involves  pain  of  § 


42  Treatment 

sharp,  shooting  character,  throbbing  with  the  pulsation 
of  the  Tcssels,  increased  in  the  horizontal  position  and 
therefore  worse  at  night,  and  by  changes  of  temperature. 
Locally,  cold  reheves  and  heat  intensifies  the  pain.  There 
is  practically  always  a  cavity  in  the  tooth,  and  contact 
with  the  interior  excites  acute  suffering,  as  the  pulp  Is 
commonly  exposed. 

Temporary  relief  may  be  secured  by  appljdng  a 
particle  of  cotton-wool  steeped  in  one  of  the  essential 
oils  such  as  that  of  cloves,  cinnamon,  or  peppermint, 
or  in  pure  carbohc  acid,  and  covering  with  another  pellet 
dipped  in  gum  mastich  or  sandrac  moistened  with  chloro- 
form. A  favourite  remedy  in  Italy,  under  the  name  of 
Odontodol,  is  composed  of  Cocaine  Hydrochlorate,  gr.  xvj, 
dilute  Hydrocyanic  Acid  -n^xv],  Tincture  of  Arnica  5  ij, 
and  Liquor  Ammonia  Acetatis  to  the  ounce.  Tension 
in  the  pulp  cavity  from  a  putrescent  pulp,  usually  in 
a  tooth  which  has  been  stopped,  requires  relief  by  opening 
the  chamber. 

Periosteal  pain — that  preceding  an  alveolar  or  root 
abscess — is  more  constant  and  gnawing  in  character. 
Tenderness  is  elicited  by  pressure  on  either  the  gum  or 
the  tooth,  and  though  biting  on  it  at  first  gives  a  sense 
of  satisfaction,  this  becomes  unbearable  as  the  inflamma- 
tion progresses.  Later  there  is  swelling  of  the  face  and 
the  pain  is  mitigated.  Appropriate  remedies  are  first 
a  purgative  such  as  a  drachm  of  sulphate  of  magnesia 
every  four  hours  for  three  doses,  or  a  colocynth  and 
calomel  pill  at  night,  with  local  removal  of  blood  by 
scarification  or  a  leech,  and  then  the  painting  of  the 
dried  gum  with  a  mixture  of  equal  parts  of  liniment  of 
iodine,  tincture  of  aconite,  and  chloroform. 

Maturation  of  the  abscess  may  be  hastened  and 
some  rehef  afforded  by  the  application  of  hot  fig  or  raisin 
poultices  or  wool  steeped  in  hot  water  in  the  sulcus 
between  the  gum  and  the  cheek,  but  poultices  over  the 


Fissure  of  Anus  43 

exterior  of  the  face  are  to  be  sedulously  avoided,  as  they 
encourage  the  bursting  of  the  abscess  through  the  skin, 
leaving  a  permanent  and  unsightly  scar. 

When  pain  has  existed  for  some  hours  and  the  forma- 
tion of  pus  is  already  probable,  its  escape  may  be  aided 
and  relief  afforded  by  carrying  a  double  thread  steeped 
in  carbolic  acid  deeply  between  the  tooth  and  edge  of 
the  gum  by  means  of  a  needle  with  the  eye  broken  so  as 
to  leave  only  a  notch  sufficient  to  hold  the  thread  in  posi- 
tion during  its  insertion,  the  thread  thus  acting  as  a  drain. 

Fissure  of  Anus. — It  is  certainly  remarkable  that 
whereas  slight  wounds  of  mucous  membrane  in  the  mouth, 
stomach,  and  rectum  usually  heal  with  great  rapidity, 
spontaneous  lesions  of  those  parts  such  as  small  ulcers 
are  extremely  persistent,  and  can  often  be  remedied  only 
by  great  care  and  patience. 

Fissure  of  the  anus  is  an  example  of  a  peculiarly 
small  and  apparently  unimportant  lesion  producing  great 
suffering,  and  which  exhibits  no  disposition  to  heal  of 
its  own  accord.  The  symptoms  are  very  characteristic, 
but  are  commonly  erroneously  referred  by  the  patient 
to  piles.  Slight  moisture  at  the  anus  and  itching  may  be 
the  only  thing  noticed  till  the  bowels  act,  when  there 
occurs  severe  rending  pain  which  may  inhibit  the  contrac- 
tion of  the  bowel,  induce  spasm  of  the  external  sphincter, 
and  persist  for  some  hours.  These  attacks  of  pain  return 
with  increasing  severity  with  each  attempt  at  defsecation, 
causing  the  utmost  misery  and  dread.  If  the  patient 
is  taken  at  her  word,  an  examination,  which  causes  a 
similar  attack  of  pain,  reveals  nothing  in  the  nature  of 
piles.  Only  a  very  careful  scrutiny  in  a  good  light  wiU 
enable  the  observer  to  appreciate  the  small  crack  or 
ulcer  partly  within  and  partly  without  the  anus,  and 
usually  at  the  posterior  aspect.  It  may  be  concealed 
by  a  fold  of  skin,  but  is  commonly  indicated  by  a  small 
vascular   projection   in    close   proximity.     The   ulcer   ig 


44  Haemorrhoids 

quite  shallow,  the  base  occupied  by  a  whitish  granular 
slough,  and  it  may  not  exceed  an  eighth  of  an  inch  in 
length.  Early  mild  cases  are  readily  cured  by  the 
application  of  nitrate  of  silver  or  even  sulphate  of  copper 
in  the  solid  form  :  a  single  application  may  suffice,  but 
the  healing  may  be  further  encouraged,  if  it  flags,  by 
applying  a  solution  of  the  same  agents  (one  grain  to  the 
ounce  of  water)  two  or  three  times  a  day.  Should  the 
ulcer  have  attained  greater  dimensions  and  not  respond 
to  this  treatment,  it  must  be  completely  exposed,  and 
the  base  divided  by  drawing  the  point  of  a  small  knife 
across  it  from  edge  to  edge,  and  the  "  sentinel  pile  " 
if  present  snipped  off. 

It  is  as  well  to  endeavour  to  heal  the  ulcer  in  the 
interval  between  the  action  of  the  bowels,  which  may 
be  extended  by  a  mild  opiate,  evacuation  being  subse- 
quently encouraged  by  a  laxative. 

H-asmopphoids  in  their  persistent  and  aggravated 
form  constitute  a  definite  surgical  complaint,  and  are  only 
to  be  cured  by  operation,  but  occasional  engorgement  or 
even  inflammation  of  the  hsemorrhoidal  veins  and  con- 
tiguous tissues  about  the  anus,  either  just  within  or 
without  the  sphincter,  is  so  common  a  malady  that 
few  escape  it,  and  many  people  suffer  from  transitory 
attacks  at  repeated  intervals  till  they  ultimately  require 
the  services  of  the  surgeon,  especially  if  treatment  is 
neglected  in  the  early  stage. 

Usually  after  a  period  of  constipation,  and  particularly 
if  this  has  been  overcome  by  strong  purgatives,  the 
development  of  piles  is  marked  by  aching  pain  in  the 
coccygeal  region,  increased  by  def  sscation,  which  is  diffi- 
cult and  painful,  and  attended  by  protrusion  of  the 
distended  mucous  membrane  conveying  a  sense  of 
obstruction.  Inflammation  and  thrombosis  of  the  dis- 
tended veins  usually  ensue,  indicated  by  a  burning 
sensation  and  often  acute  tenderness.     There  may  be 


Enteroptosis  45 

irritation  and  muco-purulent  discharge  and  occasionally 
slight  hsemorrhage  which  affords  some  relief.  Examina- 
tion with  the  finger  detects  smooth,  firm  projections  at 
the  margin  of  the  anus,  which  are  tender,  rendered  more 
prominent  by  straining,  and  when  seen  appear  as  deep 
crimson  distension  of  the  anal  folds  or  of  the  mucous 
membrane  above.  The  aching  generally  radiates  over 
the  perinseum  and  often  extends  down  the  thighs,  but  is 
usually  relieved  by  putting  the  legs  up  or  stUl  more  by 
lying  down. 

Treatment  consists  in  applying  astringents  and 
anaesthetics  locally  while  relieving  the  portal  circulation 
and  softening  the  faeces  by  mild  laxatives.  A  single 
thrombosed  and  inflamed  pile  may  be  immediately 
cured  by  incising  the  swelling  and  turning  out  the  clot 
under  a  local  anaesthetic.  The  best  local  astringent  is 
adrenahn ;  a  preparation  of  the  gland  extract  made  up 
with  lanoline  under  the  name  of  "renaglandin  "  is  a  popular 
and  effective  preparation,  and  may  be  combined  with  a 
small  quantity  of  menthol,  cocaine,  or  eucaine.  Supposi- 
tories of  hammamelin,  of  lead  and  opium,  and  galls  and 
opium,  may  also  be  used,  but  should  be  warmed  before 
insertion,  to  soften  them.  Glycerine  suppositories  are 
also  useful,  especially  when  it  is  desired  to  obtain  a  speedy 
action  of  the  bowels.  The  laxatives  in  most  general 
use  are  the  confections  of  senna,  sulphur,  or  pepper,  taken 
at  night.  Ichthyol  in  pills  of  three  grains  three  times 
a  day  has  been  recommended,  but  any  of  the  milder 
purgatives,  except  those  containing  aloes,  suffice. 

Enteroptosis. — Laxity  of  attachment  of  the  several 
abdominal  organs  may  occur  individually  or  collectively, 
the  latter  condition,  associated  with  flaccidity  of  the 
parietes,  having  been  considered  exhaustively  by  Glenard 
in  recent  years.  The  displacement  and  mobility  of  the 
kidney,  especially  on  the  right  side,  have  been  attributed  to 
tight  lacing  in  women,  and  the  same  cause  may  account  for 


4^  Enteroptosis 

other  displacements,  but  the  general  condition  of  abdomi' 
nal  laxity,  sometimes  called  Glenard's  disease,  appears  to 
result  in  all  cases  from  loss  of  bulk.  It  is  not  uncommon 
after  childbirth,  and  accompanies  rapid  wasting  from  any 
cause,  but  especially  that  which  is  associated  with  neurosis 
or  neurasthenia.  The  patients  are  women  approaching 
middle  age,  and  they  complain  chiefly  of  disability  in 
getting  about,  fatigue  and  dragging  pains  at  the  waist 
and  loins,  and  exhibit  a  tendency  to  stoop  forward  in 
walking  or  standing.  On  examining  the  abdomen,  which 
is  lax  and  thin,  the  muscles  appear  unusually  flaccid, 
and  in  well-marked  cases  the  various  organs  can  be 
grasped  through  the  loose  parietes  and  moved  freely  in 
any  direction.  It  is,  of  course,  out  of  the  question  to 
think  of  surgical  interference  in  such  a  widespread 
condition,  and  an  attempt  must  be  made  to  restore  the 
natural  tone  and  fat.  The  Weir  Mitchell  system  com- 
bined with  massage  and  electrical  stimulation  will  effect 
this,  but  many  patients  recover  if  supported  and  enabled 
to  get  about.  Two  pieces  of  five-pound  sheet  lead  are 
cut  out  to  fit  accurately  the  front  and  sides  of  the  abdomen, 
leaving  a  gap  of  two  inches  in  the  middle  line  and  half 
an  inch  along  the  bony  margin  of  the  thorax  and  pelvis. 
These  are  sewn  into  brown  hoUand  covers  having  a  free 
edge  haK  an  inch  wide,  by  which  they  may  be  pinned  or 
sewn  inside  the  corsets.  These  should  be  long  enough  to 
cover  the  lead  plates,  which  have  to  be  carefully  adjusted 
and  temporarily  attached  to  them  by  pins  while  the 
patient  is  in  the  horizontal  position.  The  corsets  can 
then  be  fastened,  the  lead  plates  becoming  moulded  to 
the  front  and  sides  of  the  abdomen  affording  firm 
and  elastic  support  to  the  viscera  through  the  medium 
of  the  gas-containing  intestines.  When  found  to  be 
rightly  adjusted,  the  plates  can  be  stitched  to  the  corsets 
and  put  on  with  theva  every  day  before  rising,  so  as  to 
retain   the   organs   in   their  proper   position.     As   they 


Mechanical  Support  47 

become  moulded  to  the  body  they  are  quite  comfortable, 
and  their  weight  does  not  exceed  two  or  three  pounds. 
After  a  time  they  crack  with  wear,  especially  on  stooping, 
but  if  the  original  pattern  is  taken  in  paper  and  retained 
they  can  easily  be  replaced,  being  slipped  into  the  old 
cases.  This  plan  enables  the  patient  to  go  about  in 
comparative  comfort,  but  should  be  persisted  in  for  three 
months  while  efforts  are  made  to  restore  the  general 
tone  and  nutrition,  and  when  these  succeed  the  plates 
may  be  dispensed  with. 

A  very  simple  means  of  applying  massage  to  the 
abdomen  is  by  rolling  a  moderately  heavy  ball  over  the 
surface  in  a  circular  manner,  from  right  to  left  across  the 
epigastrium,  downwards  in  the  left  flank,  from  left  to 
right  across  the  hypogastrium  and  upwards  in  the  right 
flank ;  following  the  course  of  the  colon.  This  has 
proved  effective  in  relieving  habitual  constipation,  and 
in  reducing  the  size  of  the  abdomen  by  bracing  the  muscles. 

The  ball  should  be  covered  with  soft  leather,  have 
a  diameter  of  four  or  five  inches,  and  weigh  about  six 
pounds.  The  most  suitable  time  for  employing  it  is 
just  before  getting  up  in  the  morning — for  about  five 
minutes. 

Discomfort  arising  from  delayed  gastric  digestion 
with  atony — a  very  common  condition — may  be  imme- 
diately relieved  by  exciting  peristalsis. 

The  patient  should  lie  on  the  right  side  and  rhythmically 
stroke  the  skin  directly  below  the  ribs  in  the  left  flank  at 
intervals  of  fifteen  seconds.  This  excites  peristaltic 
contraction  in  the  stomach  and  the  contents  can  be  heard 
gurgling  through  the  pylorus,  the  organ  being  com- 
pletely emptied  in  ten  to  fifteen  minutes. 


CHAPTER    II 
DISEASES   OF   THE   SKIN 

On  account  of  its  extreme  sensibility  and  the  disfiguring 
effect  of  anything  disturbing  its  surface,  but  few  affec- 
tions of  the  skin  can  be  lightly  regarded. 

Affording,  as  it  does,  such  a  ready  field  for  observation 
and  treatment,  the  subject  has  been  already  so  minutely 
dealt  with  by  specialists  that  practically  nothing  con- 
cerning it  is  omitted  from  modern  medical  literature. 

There  are,  however,  a  few  familiar  ailments  which 
on  that  very  account  are  rarely  brought  seriously  under 
the  notice  of  the  profession,  but  which  are  preventable 
or  remediable,  and  at  the  same  time  sufficiently  annoying 
to  be  worth  considering. 

Owing  to  variations  in  the  blood  supply  and  func- 
tional activity  of  the  skin,  with  changes  of  temperature, 
disturbances  of  the  surface  are  more  prone  to  occur  with 
the  onset  of  hot  or  cold  weather,  so  that  the  spring  and 
autumn  are  specially  productive  of  them,  and  from  time 
to  time  exposure  to  unaccustomed  influences  leads  to 
painful  reaction. 

Were  it  more  generally  understood  how  many  disorders 
of  the  skin  are  dependent  on  constipation  and  deranged 
digestion  on  the  one  hand,  and  insufficient  or  impeded 
cutaneous  excretion  on  the  other,  both  often  due  to 
physical  inactivity,  many  of  the  minor  skin  troubles 
would   be  avoided. 

The    alternation    of    full    functional    activity    with 


Baldness  49 

physiological  rest  constitutes  the  best  means  of  keeping 
every  organ,  and  the  system  generally,  in  good  working 
order,  and  of  maintaining  physical  health  ;  and,  in  the 
case  of  the  skin,  an  occasional  Turkish  bath  when  per- 
spiration is  not  excited  by  ordinary  means,  in  addition 
to  daily  bathing  and  friction,  is  very  beneficial. 

General  eruptions  dependent  on  constitutional  disease 
or  internal  derangements  will  not  be  touched  on  here, 
nor  will  any  allusion  be  made  to  the  well-known  parasites, 
only  such  common  reactions  to  external  influences  as 
are  of  familiar  occurrence  being  within  the  range  of  this 
chapter. 

Baldness. — Falling  of  the  hair — defluvium  capillitii 
—in  a  slight  degree  is  a  normal  and  continuous  process 
consequent  on  the  natural  termination  of  the  life  of 
individual  hairs,  which  then  become  detached  from  their 
follicles  and  are  presently  succeeded  by  new  ones. 

This  loss  is  accentuated  at  certain  times  of  the  year, 
notably  in  the  spring  and  autumn,  and  occurs  also  in  an 
exaggerated  degree  at  irregular  intervals  as  determined 
by  temporary  impairment  of  health  and  vigour,  such  as 
the  catamenial  periods  in  women  and  in  either  sex  as  a 
concomitant  of  indigestion,  ansemia,  acute  fevers,  and, 
indeed,  any  illness  which  reduces  the  quality  of  the  blood 
and  force  of  the  circulation  or  impairs  the  vigour  of  the 
nervous  system. 

The  persistence  of  loss  of  hair  with  defective  renewal, 
however,  in  comparatively  young  men,  sufficient  to 
produce  visible  baldness,  is  a  matter  beyond  this  natural 
process,  calling  for  explanation  and,  if  possible,  remedy. 

Actual  data  are  scarcely  obtainable,  but  that  there  has 
been  of  late  years  a  great  increase  in  the  number  of  men, 
more  or  less  bald,  between  the  ages  of  twenty-five  and 
fifty-five  is  a  very  general  and  deep-rooted  impression. 

This  is  especially  the  case  in  cities,  suggesting  the 
idea  that  it  may  be  due  to  the  wearing  of  hard  hats, 

4 


so  Effect  of  Hard  Hats 

prescribed  rather  for  the  purpose  of  ceremony  than  for 
service  or  comfort.  It  is  certainly  remarkable  that 
women  7inder  similar  conditions  of  life  do  not  so  suffer, 
and  that  baldness  is  practically  unknown  among  the 
young  and  middle-aged  of  native  races  who  wear  no  such 
headgear,  and  is  very  much  less  common  among  country- 
men and  sailors. 

An  obvious  anatomical  explanation  is  offered  in  the 
compression  of  the  nutrient  arteries  of  the  scalp  between 
the  skull  and  the  rim  of  the  hat,  which  may  not  only 
limit  the  circulation  in  the  wearing,  but  may  produce  such 
thickening  and  compression  of  the  arterial  walls  as  may 
render  diminution  of  their  calibre  permanent,  the  effect 
being  the  more  marked  owing  to  the  vertex  being  the 
highest  point  in  the  circulation,  and  the  vessels  terminal. 

Not  only  does  baldness  specially  affect  those  who 
habitually  wear  hard  hats,  but  it  specially  affects  that 
part  of  the  head  included  in  their  grip,  leaving  a  healthy 
fringe  of  hair  below  and  in  no  way  extending  to  any  part 
of  the  face.  It  may  be  observed,  too,  that  those  with 
broad  or  round  heads  are  more  frequently  affected  than 
those  whose  heads  are  narrow  or  long,  presumably  be- 
cause the  temporal  artery  in  the  latter  is  less  exposed 
to  pressure.  This  limitation  of  the  loss  of  hair  to  the 
part  included  in  the  hat  appears  quite  irreconcilable 
with  the  idea  of  independent  disease  of  the  scalp  and 
hair  follicles,  which  would  never  stop  short  at  such  an 
artificial  barrier  any  more  than  it  would  refuse  to  extend 
to  the  face.  And  it  would  appear  much  more  probable 
that  the  associated  phenomena  described  in  this  con- 
nection, such  as  scurf,  thinning  of  the  scalp,  and  diminish- 
ing thickness  and  length  of  hair,  are  all  due  to  local 
anaemia  from  compression  of  the  vessels,  and  that  the 
conditions  of  anaemia,  debility,  and  disordered  digestion, 
when  present;  are  merely  the  associated  effects  of  town 
life. 


Changes  in  Scalp  and  Hair  51 

The  variations  in  the  occurrence,  degree,  and  dis- 
tribution of  baldness  are  sufficiently  accounted  for  by 
differences  in  the  course  and  distribution  of  the  blood- 
vessels supplying  the  scalp,  and  in  the  shape  of  the  head. 
The  practical  solution,  according  to  this  view,  is  to  discard 
hard  hats,  as  some  have  already  done  ;  or  at  least  so  to 
arrange  them  that  no  pressure  is  exerted  on  the  main 
arteries  passing  upwards  in  front  of  and  behind  the  ears 
at  the  sides  of  the  head  ;  or,  better  still,  to  wear  a  full- 
sized  hat  supported  on  the  head  by  a  leather  lining 
shaped  as  a  skull  cap,  as  was  done  with  helmets  in  the 
middle  ages. 

By  such  means  baldness  may  be  prevented  or  may 
be  arrested  when  commencing,  but  it  is  very  doubtful 
if  it  can  be  cured  when  once  completely  established. 

This  is  doubtless  true  of  premature  baldness  which 
often  affects  men  in  robust  health,  and  cannot  reasonably 
be  attributed  to  any  constitutional  taint  or  even  partial 
failure  of  health. 

The  local  changes  in  the  scalp  and  hair  have  been 
well  described  by  Hebra.  The  first  period  is  that  of 
seborrhoea,  in  which  the  vertex  is  covered  with  an  im- 
mense quantity  of  thin  white  asbestos-like  scales,  con- 
tinually being  desquamated  and  renewed,  covering  the 
hair  with  a  fine  branlike  dust,  while  the  moister  part 
clings  to  the  scalp,  and,  if  neglected,  accumulates,  and 
from  admixture  with  dust,  forms  a  yellow  or  grey  crust. 
Potash  or  soda  soap  will  remove  this,  disclosing  the 
sound  skin  white  or  reddened.  Yolk  of  egg  is  an 
efficient  and  more  soothing  application,  but  whatever 
the  treatment  the  exudation  is  renewed  in  a  few  hours 
and  persists  for  months  or  years.  It  is  sometimes 
accompanied  by  slight  itching. 

The  condition  is  sometimes  associated  with  anaemia  and 
evidence  of  feeble  circulation  such  as  cold  extremities, 
with  chilblains,  congested  nose,  moist  palms  and  soles, 


52  Seborrhoea 

imperfect  digestion,  and  in  women  scanty,  painful,  or 
too  abundant  menstruation  or  other  uterine  disorders. 

Seborrhoea  commonly  begins  between  the  ages  of 
twenty  and  thirty  and  persists  till  after  forty.  The 
disorder  is  very  common,  and  those  affected  do  not 
usually  apply  to  the  physician  in  this  stage,  but  when 
the  inevitable  falling  of  the  hair  and  baldness  supervene 
in  two  to  six  years,  their  concern  is  aroused,  often  too 
late  for  remedies  to  be  effective. 

The  frontal  region  and  vertex  are  first  affected,  giving 
rise  to  two  bald  patches  which  may  become  confluent 
later.  Sometimes  the  anterior  border  of  hair  disappears, 
so  that  the  patient  is  bald  to  the  occiput  (ophiasis). 
The  scalp,  thus  denuded,  appears  white,  smooth,  and 
shiny.  It  is  tightly  stretched  over  the  skull,  thin,  and 
can  only  be  pinched  up  with  difficulty.  At  first  numerous 
fine  short  slightly  pigmented  hairs  appear,  and  this  is 
an  indication  that  recovery  under  suitable  treatment 
may  be  hoped  for  ;  later,  when  these  have  vanished, 
nothing  can  be  expected  of  remedies. 

The  duration  of  life  of  any  individual  hair  varies 
according  to  its  position  and  with  the  age  and  state  of 
health  of  the  person.  After  persisting  for  months  or 
years,  it  normally  falls  out  and  is  replaced  by  a  fresh 
one  from  the  same  or  a  neighbouring  papilla. 

The  thicker  the  individual  hair  the  longer  it  remains 
attached  to  its  papilla  and  the  greater  length  it  attains. 
As  the  physiological  term  of  life  shortens,  so  the  length 
and  thickness  likewise  diminish.  There  is  also  an  interval 
between  the  shedding  of  a  hair  and  the  appearance  of 
its  successor  amounting  to  some  weeks.  When  the 
nutrition  of  the  hair  is  failing,  at  first  few,  then  many^ 
hairs  suffer  diminution  in  length  and  thickness  and  in 
their  term  of  life.  Seborrhoea  causes  a  disturbance  in 
the  reproduction  of  the  hair  :  it  represents  a  too  a'mindant 
production  of  cells  by  the  sebaceous  glands,  associated 


Treatment  53 

with  chemical  change  in  the  direction  of  fatty  impregna- 
tion. The  cells  of  the  outer  root-sheath  corresponding 
with  the  rete  mucosum  are  continued  without  inter- 
ruption into  the  sebaceous  glands,  and  the  same  change 
which  occurs  in  them  extends  presently  to  the  root- 
sheath  of  the  hair.  In  consequence  of  such  an  alteration 
in  nutrition  and  the  mechanical  separation  of  its  elements, 
the  hair  must  necessarily  be  shed.  If  this  numerical 
hyperplasia  of  the  cells  of  the  root-sheath  diminishes,  the 
cells  become  more  stable  and  a  new  hair  may  be  formed. 
They  may  either  then  nourish  a  new  hair  formed  from 
the  old  papilla,  or  they  may  themselves  undergo  trans- 
formation in  their  central  portion  into  a  hair.  This 
return  to  a  regular  production  of  hair  actually  occurs 
in  very  advanced  stages  of  alopecia  furfuracea  ;  but 
after  seborrhcea  has  persisted  for  six  to  ten  years  or 
more  while  the  production  of  new  hairs  has  been  in 
abeyance,  a  return  to  the  normal  condition  is  not  at  all 
probable,  and  at  length  is  no  longer  possible,  the  papilla 
and  vessels  having  become  so  changed  (atrophied)  that 
they  are  no  longer  capable  of  producing  new  cells  for  the 
formation  of  a  fresh  hair  bulb.  Baldness  is  then  per- 
manent. 

Loss  of  hair  occurring  in  the  course  of  acute  or  chronio 
illness  may  be  due  either  to  simple  trophoneurosis, 
or  to  seborrhcea  then  commencing  and  continuing 
after  health  has  been  restored,  as  an  independent 
affection. 

Treatment. — The  first  step  in  the  application  of 
remedies  is  the  removal  of  the  sebaceous  crust  from  the 
scalp.  The  accumulation  of  scales  must  be  softened  by 
carefully  rubbing  oHve  oil  or  paraffin  into  the  skin  of 
the  head  and  leaving  this  aU  night,  protected  by  a  cap. 
After  twelve  to  twenty-four  hours  the  head  is  well  washed 
with  soap,  the  most  satisfactory  preparation  being  the 
Spiritus  Saponatus  Kalinus,  prepared  by  digesting  soft 


54 


Treatment 


soap  in  half  its  bulk  of  rectified  spirit,  filtering,  and 
scenting  with  spirits  of  lavender.  The  scalp  is  washed 
with  a  sufficient  quantity  of  the  solution,  the  addition 
of  a  little  warm  water  from  time  to  time  effecting  a 
lather  which  is  subsequently  thoroughly  riased  away 
with  cold  or  lukewarm  water. 

Anointing  with  oil  is  only  necessary  for  the  first  few 
days  until  the  sebaceous  crust  is  entirely  removed,  but 
the  daily  washing  with  soap  solution  and  water  should 
be  continued  for  months,  the  hair  and  scalp  being  allowed 
to  dry  and  the  fat  being  replenished  with  some  oil  or 
pomade.  Later  a  spirit  lotion  without  soap  may  be 
employed. 

These  are  the  essentials  of  treatment,  but  modern 
pharmacists  have  usually  added  to  the  pomade  or  spirit 
lotion  employed  in  the  later  phases  certain  drugs  having 
a  reputation  for  promoting  the  growth  of  hair,  perhaps 
from  some  effect  in  causing  irritation  and  redness  of 
the  skin.  There  is  no  objection  to  their  use,  and  the 
following  are  some  of  the  formulae  advocated: 


Erasmus  Wilson. 
01.  Amygdalae,  §  j 
Liq.  Ammonias,  §  J 
Eau  de  Cologne,  g  j 
01.  Eosmarini,  3  iij 
01.  Myristicse,  3iv 
Tinct.  Jaborandi  gj 
Aq.  Rosas,  ad.  §  viij 


Lotions. 

Hebea. 
Tinct.  Canthar.  3  ss,  or 

Ac.  Tannici,  gr.  xij 
Sp.  Vin.  Eectif.  gv 
Sp.  Lavandulas,  gj 
Ether.  Sulphurat.  3  ij 
Glycerini,  3  iv 
01.  Bergamot,  v\  x 


Qnin.  HydrocM.  gr.  xxiv 
Acid.  Tannici,  3  j 
Alcohol.  (60%),  g  xss 
Tinct.  Cantharid.  3j 
Glycerini,  3vj 
Eau  de  Cologne,  3  iv 
Vanilin,  gr.  ss 
Lign.  Santal,  gr.  iij 
Pilocarpin  Nitrat.  gr.  iv 


«Iix.  Macerate  4  days 
and  filter. 


To  be  well  nibbed  into  the  scalp  night  and  morning. 


Papules 


5S 


Pomades. 

DUPUTTEEN. 

Medullas  Ossium,  g  ij 
Extract.  Cinchonse,  3  ij 
Tinct.  Cantharid.  5  j 
Succi  Citri,  3  j 
Olei  Limonis,  tii  xs 
Olei  Bergamot,  ni  x 


Gemmabum  Populi. 
Eesin.  Gem.  Populi,  §  j 
Adip.  prjep.,  5  vj 
Aq.  Kosas,  tn,  160  ;  heat 

together  and  add 
01.  Citri,  V!\,  X 
01.    Bergamot,  tn,  x 
01.  Eosmarin,  v\,  x 


Tanno-Quinine. 
01.  Theobr,  §  jss 
Ung.  Emollient,  5  ss 
01.  Amygdalse,  §  jss 
Quinin.    Sulph.    gr.    x 

diss,    with    acid    in 

Aq.  Rosse,  §  ss 
Olei  Citri,  3  ss 
01.  Bergamot,  ni  xx 
01.  Lavandulas,  ni  sx 
Ac.  Tannici,  gr.  xl 
Tinct.  Canthar.  3  j 
Eau  de  Cologne,  3  iij 

These  are  used  to  lubricate  the  scalp  after  evaporation 
of  the  spirit  lotions. 

It  may  here  be  repeated  that  on  scientific  grounds 
alopecia  furfuracea  is  curable  during  the  first  few  years 
of  its  existence,  if  the  seborrhcea  causing  it  be  removed 
by  persistent  and  energetic  use  of  the  Spiritus  Saponatus 
Kalinus  and  of  the  alcohoHc  ethereal  fluids  with  the 
occasional  addition  of  fatty  material  to  the  epidermis, 
whenever  it  has  become  too  dry.  Recovery  will  be  aided 
by  tonics,  especially  arsenic  and  iron,  with  convalescent 
diet  and  surroundings,  persisted  in  for  six  months.  This 
regime  may  be  followed  in  chlorosis  or  after  fevers  and 
acute  diseases,  but  apart  from  these  the  treatment  of 
incipient  baldness  will  probably  be  limited  to  local 
remedies,  and  it  is  not  always  easy  to  ensure  the  efficient 
appHcation  of  these  for  a  sufficient  time. 

Papules. — The  formation  of  pimples,  particularly 
about  the  face  and  neck,  is  mostly  due  to  inflammation 
of  hair  follicles  or  the  associated  sebaceous  glands.  They 
may  be  either  pale  or  red,  and  sometimes  present  a  yellow 
point  from  the  formation  of  a  minute  quantity  of  pus. 
Apart  from  trifling  itching  they  are  chiefly  objectionable 
on  account  of  their  appearance,  and  if  rubbed  may  not 
disappear  for  days.  Should  there  be  a  tendency  to  the 
formation  of  sticcessive  crops,  it  is  best  to  treat  the  patient 


56  Stye 

constitutionally  by  some  laxative  such  as  sulphur  lozenges 
or  salts  every  morning  till  they  subside,  or  calcium  sulphide 
in  pills  (gr.  1/4)  may  be  given  internally ;  otherwise,  touch- 
ing individual  pimples,  when  they  first  show  themselves, 
with  toilet  vinegar  or  colourless  solution  of  iodine  will 
usually  abolish  them  ;  even  the  ordinary  tincture  may  be 
used  at  night,  as  the  colour  vanishes  in  a  few  hours. 

When  a  small  yellow  head  has  appeared,  pressure 
with  a  small  key  will  evacuate  pus  or  sebaceous  matter 
and  hasten  subsidence. 

Stye  (Hopdeolum)  occurring  on  the  margin  of  the 
eyelid  and  due  to  inflammation  of  the  ciliary  follicles  is 
of  the  same  nature  and  runs  much  the  same  course  as 
the  preceding,  but  is  even  more  painful  and  disfiguring  and 
usually  leads  to  considerable  swelling  and  redness  of  the  lid, 
owing  to  looseness  of  the  cellular  tissue.  Some  individuals 
are  specially  prone  to  develop  styes,  which  may  succeed 
one  another  for  some  weeks  on  account  either  of  the  con- 
stitutional state  of  the  subject  or  owing  to  auto-infection. 

Lawson  recommends  painting  the  lid  with  collodion 
or  touching  the  spot  with  mitigated  nitrate  of  silver  in 
the  very  early  stage,  taking  special  care  that  none  gets 
into  the  eye.  Where  an  eyelash  can  be  seen  emerging 
from  the  inflamed  spot,  its  removal  with  forceps  often 
expedites  recovery,  and,  as  it  is  generally  already  loosened, 
this  is  not  so  painful  as  might  be  expected.  Should  the 
inflammatory  process  continue  in  spite  of  these  measures, 
recourse  must  be  had  to  hot  fomentations  or  decoction 
of  poppy-heads  applied  under  oil-silk  at  night,  leaving 
the  pus  to  find  an  exit  for  itself.  The  lids  may  subse- 
quently be  bathed  with  a  lotion  composed  as  follows  : 

5^.  Sodae  Bicarb.  .        ,        ,        ,  5  j 

Boracis 5j 

Acid.  Hydrocyan,  dil.       .        .        .      fl.  5] 
Aquae  Sambuci  ,        .        .        ,      fl.  3  ij 

Aquam  destill.  .        .        .        ,         ad.  §  viij 

the  Unguent.   Hydrarg.  Nitratis,   in  the  proportion  of 


Folliculitis  57 

one  drachm  to  seven  drachms  of  white  vaseline,  being 
painted  on  the  lid  at  night. 

The  administration  of  a  laxative  followed  by  a  tonic 
mixture  of  the  mineral  acids  with  bark,  or  quinine  and 
iron,  may  be  required  where  there  is  failure  of  the  general 
health  or  a  succession  of  styes. 

Folliculitis  of  the  Buttocks. — Another  form  of 
local  though  more  extensive  pimple  formation,  usually 
occurring  in  young  men,  is  the  outcrop  of  papules  on 
the  buttocks  which  sometimes  accompanies  rowing  or 
riding.  It  is  due  to  pressure  and  friction,  and  is  mostly 
developed  at  the  commencement  of  the  exercise,  sub- 
siding of  its  own  accord  with  rest,  though  extending  if 
neglected  and  sometimes  leading  to  very  uncomfortable 
sores  if  infected.  Those  with  thick  and  opaque  skins 
are  most  liable  to  suffer.  The  most  convenient  remedy 
is  a  powder  composed  of  equal  parts  by  weight  of  zinc 
oxide  and  starch  applied  for  two  or  three  days  while 
the  particular  exercise  is  desisted  from ;  and  a  daily 
rubbing  with  alcohol  in  any  form  such  as  whisky,  eau 
de  Cologne,  or  even  methylated  spirit  is  a  good  prophy- 
lactic in  the  case  of  those  who  are  prone  to  this  affection. 

A  closely  alUed  and  still  more  common  trouble  is 
the  pimple  or  small  boil  which  is  apt  to  form  at  the  back 
of  the  neck  from  pressure  of  the  collar,  and  especially 
its  edge.  Owing  to  persistence  of  the  irritation  these 
sometimes  assume  quite  formidable  dimensions,  and  not 
only  suppurate  but  infect  the  neighbouring  skin,  pro- 
ducing discomfort  of  indefinite  duration.  One  essential 
of  treatment  is  the  removal  of  pressure,  and  if  pus  has 
already  formed,  the  evacuation  of  this  by  puncture. 
Subsequent  insertion  of  a  little  carbolic  acid  affords  the 
speediest  cure.  Bearing  in  mind  the  liability  of  local 
infection,  some  weak  perchloride  of  mercury  or  carbolic 
lotion  may  be  dabbed  on  the  surrounding  skin  or  a  small 
perforated  protective  plaister,  as  that  of  opium,  applied 


58  Bites  and  Stings 

to  the  spot  itself ;  but  wearing  a  loose  bandage  or  hand- 
kerchief round  the  neck  as  is  commonly  done  only 
increases  the  trouble.  As  constitutional  remedies,  ordi- 
nary pitch  or  ichthyol  in  three-grain  pUls,  thrice  daily, 
have  been  given  with  good  effect. 

The  Injuries  inflicted  by  Insects  are  with  few 
and  unimportant  exceptions  due  to  the  inoculation  of 
venom.  They  may  be  bites,  stings,  or  penetrations 
of  the  proboscis  for  the  purpose  of  suction. 

Ants  and  spiders  inflict  minute  wounds  with  the 
mandibles,  simultaneously  injecting  an  acrid  fluid, 
irritant  to  human  beings,  though  lethal  to  other 
insects  attacked.  The  bites  of  spiders,  which  are  rare, 
and  even  questioned  in  temperate  climates,  like  those 
inflicted  by  rats,  may  be  aggravated  by  the  intro- 
duction of  matter  derived  from  putrescent  food, 
the  wounds  inflicted  being  actually  septic.  For  the 
most  part,  saving  the  accidental  introduction  of  specific 
diseases  such  as  malaria,  yellow  fever,  plague,  sleeping 
sickness,  anthrax,  cholera,  typhoid  fever,  leprosy, 
beri-beri  and  filaria  sanguinis  hominis — aU  of  which  have 
been  attributed  to  insects,  and  particularly  mosquitoes — 
the  insertion  of  the  proboscis  in  feeding  only  produces 
irritation  dependent  on  the  instillation  of  the  secretion 
of  the  salivary  gland,  which  assists  the  flow  of  blood. 
This  is  the  case  with  fleas,  bugs,  most  varieties  of  flies, 
and  has  been  experimentally  proved  in  the  leech. 

On  the  other  hand,  bites  and  stings  inflicted  in 
defence  or  anger  are  immediately  painful,  and  may  even 
prove  dangerous  by  reason  of  the  severity  or  locaUty  of 
the  injury  or  the  constitutional  state  or  idiosyncrasy 
of  the  patient. 

Prolonged  disturbance  may  result  from  the  continuous 
irritation  of  creatures  which  bury  themselves  in  the  skin, 
such  as  the  jigger  {Pulex  penetrans),  the  itch  insect 
{Sarcoptes  scahiei),  or  the  harvest  bug  {Leptiis  autumnalis), 


Remedies  59 

but  even  the  insertion  of  the  proboscis  may  lead  in  some 
skins  to  the  formation  of  a  papule  or  vesicle  which 
continues  to  give  rise  to  itching  for  several  days,  par- 
ticularly on  washing  the  skin  or  changing  the  clothing. 
This  is  evidently  due  to  an  irritant  fluid,  for  if  the  spot 
be  pricked  and  pressed  with  a  watch-key,  a  drop  of  clear 
fluid  exudes  and  the  irritation  at  once  ceases. 

The  irritant  associated  with  the  ant  {Formica)  is  the 
first  acid  of  the  Methylene  series,  and  named,  after  the 
insect,  formic  acid.  Its  peculiar  odour  is  easily  identified 
emanating  from  an  ant's  nest  which  has  been  disturbed. 
The  same  acid  has  been  identified  in  the  hair-glands  of 
the  stinging  nettle,  which  produces  an  identical  injury 
on  the  skin.  The  stings  of  bees  and  wasps  effected  by 
the  modified  and  envenomed  ovipositor  of  the  worker 
or  sterile  female  are  commonly  held  to  owe  their  malig- 
nancy to  the  same  agent,  deposited  more  freely  and 
deeply  in  the  tissues. 

Some  mitigation  of  the  more  superficial  stings  may 
be  obtained  by  the  application  of  water  or  the  alkaline 
juice  of  any  succulent  plant  to  the  injured  skin,  though 
a  solution  of  soda  or  ammonia  is  more  effectual,  pro- 
vided there  is  no  delay,  for  the  essential  point  is  to 
dilute  or  neutrahse  the  acid  before  reaction  in  the  form 
of  swelling  and  hyperaemia  occurs  and  closes  the  minute 
external  orifice  of  the  hurt.  The  deeper  injuries  of  the 
hymenoptera  are  popularly  treated  on  the  same  principle, 
the  blue-bag,  soap,  or  a  spht  onion  being  the  immediate 
agents  employed :  these  all  contain  free  alkali,  and  their 
homeliness  may  be  excused  on  account  of  their  generally 
being  ready  to  hand,  but  a  fairly  strong  solution  of 
ammonia,  potash,  or  soda  is  the  more  appropriate  and 
effectual  remedy  if  apphed  at  once. 

In  The  Medical  Record  for  February  8,  1890,  Dr.  Ricord 
of  New  Jersey  reports  an  instance  of  the  immediate 
cure  of  a  hornet's  sting  by  the  apphcation  of  a  spray  of 


6o  Severe  Stings 

peroxide  of  hydrogen  to  the  abeady  swollen  cutis.  Though 
this  is  an  isolated  case,  it  suggests  that  this  powerful 
agent  may  prove  of  service  in  the  local  treatment  of 
envenomed  wounds  of  even  a  more  serious  nature,  and 
even  the  weaker  solution  which  is  usually  in  the  surgery 
as  ozonic  ether  may  prove  of  value  in  deaUng  with  the 
stings  of  bees  and  wasps. 

Exceptional  instances  are  recorded  from  time  to  time 
in  which  vertigo,  syncope,  and  collapse  have  ensued  on 
such  injuries,  not  necessarily  from  a  multiplicity  of  punc- 
tures or  even  recurring  in  the  same  subject  on  another 
occasion,  the  inference  being  that  these  symptoms,  which 
occur  immediately,  are  due  to  the  direct  instillation  of 
the  poison  into  a  vein,  the  absence  of  resistance  from  sohd 
tissues  possibly  encouraging  a  more  liberal  dose.  This 
view  is  supported  by  the  slight  local  reaction  in  such  cases 
and  by  the  observation  of  similar  effects  associated  with 
the  hypodermic  injection  of  morphia  under  like  circum- 
stances. Appropriate  treatment  in  such  an  event  would 
be  general  rather  than  local,  consisting  of  the  administra- 
tion of  stimulants,  especially  ammonia  or  sal  volatile,  or 
even  the  subcutaneous  injection  of  ether. 

Pel-haps  the  most  formidable  injuries  which  have 
been  attributed  to  bees  and  wasps  are  those  unfortunate 
instances  reported  from  time  to  time  of  these  insects 
being  taken  into  the  mouth  or  actually  swallowed  either 
in  fruit  or  some  beverage.  The  swelling  resulting  from 
a  sting  in  the  tongue  or  in  the  neighbourhood  of  the 
larynx  then  causes  great  distress  from  a  sense  of  impending 
suffocation  added  to  the  pain  and  alarm,  and  unless  this 
can  be  rapidly  relieved  by  scarification,  or  the  air  passage 
kept  open  by  mechanical  means,  laryngotomy  must  be 
resorted  to,  as  death  has  actually  occurred  under  such 
circumstances.  Some  relief  may  be  obtained  by  sucking 
ice  or  applying  adrenalin,  but  for  some  hours  such  cases 
give  rise  to  great  anxiety. 


Harvesters  6i 

For  the  most  part  the  attacks  of  gnats  and  midges, 
and  even  of  mosquitoes,  are  too  general  to  admit  of 
individual  local  treatment.  Under  some  circumstances, 
especially  in  the  tropics,  it  may  be  considered  worth  while 
to  wear  a  wide  veil  at  the  periods,  usually  after  sundown, 
when  they  are  most  prevalent.  It  is  also  as  well  to 
avoid  exposing  the  ankles  even  indoors ;  thus  open 
slippers  should  not  be  worn,  better  protection  being 
afiEorded  by  thin  moccasins  or  the  old-fashioned  buskins 
into  which  the  trousers  may  be  tucked,  the  ankles 
being  a  favourite  point  of  attack. 

Even  in  hot  weather  in  temperate  climates  such 
measures  are  fortunately  hardly  worth  submitting  to,  but 
the  less  aggressive  creatures  may  be  warned  off  by  the  use 
of  carbolic  soap,  inunction  with  the  oils  of  lemon,  citronella, 
or  sassafras  or  thymol  in  the  proportion  of  ten  grains  to 
the  ounce  of  vaseline,  or  still  more  conveniently  by  a 
concentrated  extract  of  pyrethrum  in  eau  de  Cologne. 

The  Harvest  Bug",  also  known  as  the  Mower's  Mite 
{Leptus  autumnalis),  practically  unknown  in  towns,  but 
only  too  familiar  in  certain  parts  of  the  country  as  the 
immediate  cause  of  insupportable  itching,  is  itself  so 
small  as  to  be  almost  invisible. 

Gilbert  White,  in  The  Natural  History  of  Selhorne, 
writes  (Letter  xxxiv.)  :  "  There  is  an  insect  with  us, 
especially  on  chalky  districts,  which  is  very  troublesome 
and  teasing  all  the  latter  end  of  the  summer,  getting 
into  people's  skins,  especially  those  of  women  and  children, 
and  raising  tumours  which  itch  intolerably.  This  animal 
(which  we  call  a  harvest  bug)  is  very  minute,  scarce  dis- 
cernible to  the  naked  eye  ;  of  a  bright  scarlet  colour,  and 
of  the  genus  Acarus.  They  are  to  be  met  with  in  gardens 
on  kidney  beans,  or  any  legumens,  but  prevail  only  in  the 
hot  months  of  summer.  Warreners,  as  some  have  assured 
me,  are  much  infested  by  them  on  chalky  downs,  where 
these  insects  swarm  sometimes  to  so  infinite  a  degree  as 


62  Effects  of  Bites 

to  discolour  their  nets,  and  to  give  them  a  reddish  cast, 
while  the  men  are  so  bitten  as  to  be  thrown  into  fevers." 
This  larval  acarus  is  J  mm.  in  diameter,  globular 
in  shape,  having  a  fused  cephalo-thorax  divided  by  a 
transverse  furrow  from  the  abdomen.  The  legs  are  long, 
six- jointed,  with  two  sickle-like  claws  on  the  tarsus, 
and  there  are  no  discoverable  sexual  organs.  The  colour 
has  been  variously  described  as  orange,  scarlet,  or  brick- 
red,  and  the  creature  resembles  as  nearly  as  anything  a 
fine  grain  of  cayenne  pepper.  For  its  size,  it  moves  rapidly, 
and  usually  invades  human  beings  by  crawling  over  the 
feet,  though  it  may  do  so  by  the  hands  while  picking  fruit, 
or  gain  direct  access  to  the  body  of  any  one  reclining  on 
the  ground.  The  eggs  are  laid  in  June  and  July,  the 
larvae  hatching  out  in  July  and  August.  They  abound 
on  dry  soil  in  hot  dry  weather,  and  are  most  often  en- 
countered in  stubble  fields,  on  downs,  by  the  roadside, 
and  in  gardens,  where  they  are  specially  plentiful  on 
French  beans,  hops,  and  fruit  bushes  ;  though  in  the 
districts  they  favour  their  distribution  is  pretty  general. 
In  wet  seasons  and  beside  rivers  they  are  not  met  with. 
Owing  to  the  development  of  these  pests,  which  varies 
with  the  character  of  the  soil  and  season,  occurring  about 
the  period  of  the  annual  vacation,  the  irritation  set  up 
hj  them  usually  comes  as  an  unpleasant  surprise  to 
hoHday-makers,  all  the  more  probably  since  the  agent 
is  not  seen,  and  its  effects  are  commonly  delayed  for  some 
hours  after  exposure,  generally  asserting  themselves 
at  night,  after  a  day  in  the  country.  The  ankles  and 
legs  are  mostly  affected,  but  always  the  covered  parts 
of  the  body  or  limbs,  and  principally  regions  subject  to 
pressure,  such  as  the  waist,  neck,  wrists,  or  knees.  This 
may  be  a  question  of  moisture,  as  the  axillse  are  commonly 
attacked,  or  it  may  represent  places  where  the  migrations 
of  the  acarus  are  arrested.  Scattered  spots  may  occur 
on  any  part  of  the  limbs  or  trunk,  but  the  hands  and 


Prevention  and  Remedy  63 

face  escape,  affording  a  contrast  to  the  injuries  inflicted 
by  gnats.  Having  selected  its  point  of  attack  the  acarus 
burrows  into  the  skin  with  the  aid  of  sharp  mandibles, 
burying  the  cephalo-thorax,  but  not  the  abdomen.  It 
evidently  secretes  some  irritant  substance  to  encourage 
exudation,  and  by  suction  swells  to  four  or  five  times  its 
original  size,  at  the  same  time  causing  a  weal  as  large 
as  a  threepenny -piece  which  burns  and  itches  intolerably. 
The  torment  is  unfortunately  not  limited  to  the  single 
occasion,  but  recurs  every  time  the  clothes  are  changed 
or  a  bath  taken,  and  interferes  with  sleep  at  night  for  a 
week  or  more,  evidences  remaining  perhaps  for  a  month. 
In  children  and  persons  of  nervous  excitability,  especially 
where  the  bites  are  numerous,  a  sKght  degree  of  fever 
may  be  produced,  or  general  urticaria  may  result. 

Preventive  measures  are  obviously  the  most  important 
in  connection  with  this  pest.  Those  who  have  the  pain 
of  its  acquaintance  are  usually  content  to  avoid  its  haunts 
during  the  larval  period  in  the  hot  weeks  of  July  and 
August,  and  at  least  endeavour  to  expose  themselves 
as  little  as  possible  to  their  attacks  by  delegating  garden 
operations  to  those  less  susceptible,  and  by  leaving  stubble 
fields,  dry  downs,  and  field-paths  severely  alone  in 
affected  districts.  Some  protection  may  be  secured  by 
smearing  the  ankles  with  oil  of  citronella  or  sassafras 
or  a  solution  of  thymol  in  vaseline  (10  grains  to  the 
ounce)  effected  with  the  aid  of  heat,  or  pyrethrum  in  eau 
de  Cologne.  A  continuous  covering  of  thin  close-textured 
underclothing  is  also  to  be  recommended. 

If  the  skin  be  stretched  tiU  the  spot  becomes  pale, 
a  small  orange  point  can  usually  be  discerned  where  the 
creature  is  buried,  and  if  pressure  is  exerted  here  by  the 
approximated  finger-nails  or  with  a  small  key,  a  drop  of 
fluid  can  be  extracted  and  the  subsequent  duration  of 
irritation  much  abbreviated,  but  this  is  a  tedious  and 
difficult  matter  when  the  bites  are  very  numerous,  and 


64  Caterpillar  Rashes 

the  application  of  sal  volatile,  vaseline,  or  carbolised  oil 
must  be  resorted  to.  In  worse  cases  naphthol,  weak 
sulphur,  or  white  precipitate  ointment  should  be  employed. 

Plant  and  Cateppillap  Rashes. — Local  derma- 
titis due  to  penetration  of  the  skin  by  the  hairs  of  caterpillars 
and  plants  is  occasionally  met  with  in  those  coming  in 
contact  with  them,  usually  schoolboys  or  persons  occupied 
in  gardening.  It  is  seldom  seen  in  cities,  and  so  rarely 
comes  under  the  notice  of  members  of  the  medical  pro- 
fession that  many  have  no  experience  of  the  complaint, 
though  it  is  famihar  enough  to  those  immediately  con- 
cerned. The  chief  characteristic  is  the  limitation  of 
urticarial  or  erythematous  patches  to  the  hand,  and 
sometimes  to  the  neck  and  face  on  the  same  side,  or  any 
other  part  of  the  body  that  is  within  reach  of  the  affected 
limb,  these  secondary  lesions  being  self-inflicted. 

When  recently  acquired  there  is  much  tinghng  and 
irritation,  accompanied  by  some  hyperaemia  and  swelling, 
with  the  appearance  of  erythematous  spots  and  patches 
or  weals.  These  subside  in  a  few  hours,  and  are  followed 
in  two  or  three  days  by  limited  desquamation. 

Minute  vesicles  form  which  dry  and  separate  with 
a  ragged  circular  edge,  sometimes  coalescing  to  form 
irregular  patches.  On  very  superficial  observation  they 
might  suggest  scarlatina  in  a  late  stage,  but  are  usually 
unsymmetrical,  and  never  involve  the  feet,  or  indeed 
any  covered  portion  of  the  skin.  Moreover,  the  centre 
of  each  patch  may  be  seen  with  a  lens  to  be  marked  by 
a  fine  point  representing  the  irritant.  In  the  case  of 
caterpiQar  rash  the  usually  black  hairs,  though  broken 
off  short,  are  plainly  visible  ;  the  colourless  hairs  or 
raphides  of  plants  are  less  obvious.  When  questioned, 
however,  with  such  a  possibihty  in  mind,  patients  may 
recall  having  exposed  themselves  to  this  source  of  irrita- 
tion either  consciously  in  handling  hairy  caterpillars  or 
particular  plants,  or  unconsciously  in  a  country  excursion, 


Plant  Rashes  65 

while  pushing  through  bushes  or  sitting  on  the  ground, 
where  caterpillars  or  their  discarded  skins  may  not  have 
been  noticed.  It  is  only  the  stiff-haired  varieties  that 
give  rise  to  this  trouble,  particularly  those  known  collo- 
quially as  woolly  bears  and  palmer  worms  ;  but  there  are 
many  varieties,  and  the  numbers  vary  widely  with  locality 
and  season,  so  that  at  long  intervals  or  in  certain  places 
there  may  be  a  veritable  epidemic,  such  as  occurred  in 
Hyde  Park  in  1906. 

The  plants  which  more  especially  cause  these  eruptions 
are  none  of  them  wild  in  this  country,  but  are  encountered 
in  the  garden  or  greenhouse,  and  as  their  objectionable 
qualities  are  not  exactly  notorious  and  do  not  manifest 
themselves  immediately,  unconscious  victims  are  met 
with  from  time  to  time. 

The  principal  ones  are  Primula  obconica  and  Primula 
sinensis.  In  The  Lancet  for  April  25,  1891,  Dr.  S.  A.  L. 
Swan  recorded  two  cases  which  came  under  his  care,  in 
which  the  effects  of  handling  the  former  resembled  acute 
eczema  or  erysipelas  as  regards  local  appearance,  the 
absence  of  any  general  symptoms  being  a  distinguishing 
feature.  The  immediate  source  of  the  injury  has  been 
traced  by  Dr.  Riehl  of  Vienna  to  the  minute  hairs  on 
the  leaves  and  stalks.  The  cause  and  effects  are  similar 
in  both  varieties,  but  Primula  sinensis  is  the  less  virulent 
of  the  two. 

A  condition  resembling  eczema  of  the  face  and  hands 
has  been  produced  in  persons  handling  and  cleaning  the 
bulbs  of  hyacinths,  and  especially  those  of  Roman 
hyacinths  (var.  albulus),  the  prime  agents  being  the 
needle-shaped  crystals  or  raphides  composed  of  oxalate 
of  lime  measuring  o^o  to  x^  hich  in  length,  which 
are  arranged  in  close  bundles  and  are  easily  dispersed  by 
rubbing  the  dry  scales. 

The  corms  of  the  common  arum  hly  are  similarly 
provided,    and   it   is   recorded   that   the   laundresses   of 

5 


66  Plant  Rashes 

Funchal,  Madeira,  once  tried  to  utilise  the  starch  obtain- 
able from  them,  but  complained  of  the  irritation  in  the 
hands  produced  by  it,  which,  on  examination,  was  found 
to  result  from  the  presence  of  numerous  needle-shaped 
raphides. 

Other  plants  which  have  in  individual  instances 
exhibited  irritating  qualities  are  the  common  feather 
few,  elder  leaves,  and  buttercups.  The  common  nettle 
is  too  well  known  to  require  mention,  except  to  point 
out  that  its  stinging  property  is  due  to  silicious  hairs, 
crushed  by  firm  handling,  but  which  penetrate  the  skin 
coming  into  light  contact  with  them.  The  irritation  is 
produced  by  formic  acid  as  in  the  ant,  conveyed  through 
the  hair  from  a  gland  at  the  base,  and  may  be  mitigated 
by  the  immediate  application  of  moisture,  or  the  alkaUne 
juice  of  any  plant,  the  dock  leaf  being  a  popular 
favourite. 

Other  species  exerting  poisonous  effects  and  of 
colonial  origin  are  Phebalium  Argentum,  "  the  Western 
Australian  Blister  plant,"  which  blisters  the  human  skin 
when  handled,  its  acridity  being  due  to  an  essential  oil ; 
and  Dysoxylon  Bichii,  locally  called  "  mastenea  "  in  the 
Polynesian  islands,  the  wood,  sap,  or  sawdust  of  which 
causes  dermatitis  of  the  hands,  inflammation  of  the 
eyes,  and  a  burning  sensation  in  the  throat. 

Dysoxylon  Muelleri,  the  Red  Bean,  and  Castanosper- 
mum  australe,  the  Black  Bean,  woods  of  New  South 
Wales,  are  both  credited  with  producing  injurious  effects 
in  those  working  them ;  the  former  giving  rise  to 
violent  catarrh  with  vomiting  and  epistaxis,  besides 
dermatitis  and  the  poisoning  of  wounds  inflicted 
by  it. 

Cassinea  aculeata,  "  Dogwood,"  and  Eucalyptus  macu- 
lata  exert  a  somewhat  similar  effect  on  the  skin,  the 
so-called  Spotted  Gum  rash  being  especially  prevalent 
in  Mount  Douglas,  Paterson,  N.S.W. 


Remedies  67 

In  North  America,  the  Poison  Ivy,  Rhus  radicans 
(Toxicodendron),  Rhus  diversiloba  or  Poison  Oak,  and 
the  Rhus  vernix  or  Poison  Sumach,  exert  a  like  influence, 
due  to  the  presence  of  a  non- volatile  oil. 

An  efficient  application  to  the  skin  so  affected  is  a 
saturated  solution  of  lead  acetate  in  proof  spirit,  which 
combines  the  advantages  of  an  evaporating  lotion  and  an 
astringent. 

It  is  a  peculiarity  of  many  of  these  poisonous  influ- 
ences that  certain  individuals  appear  more  predisposed 
to  them  than  do  others,  just  as  does  the  liability  to 
hay  fever  and  to  the  development  of  nettlerash  after 
sea-bathing  differ  in  different  people.  And,  as  in  these 
more  familiar  cases,  the  persons  affected  do  not  become 
less  prone  to  attacks  by  repeated  exposure  and  can  only 
escape  suffering  by  avoidance  of  the  noxious  agents. 

Since  the  introduction  of  teak,  now  so  much  used  in 
this  country  for  ship-building,  fireproof  floors,  and  stair- 
cases, many  small  inflamed  wounds  have  arisen  from 
punctures  and  abrasions  in  those  working  it,  and  those 
engaged  in  fret-sawing  usually  suffer  from  the  irritating 
character  of  the  dust  while  using  that  and  other  varieties 
of  timber,  especially  rosewood. 

Sun  Eczema. — Erythema  solare  is  due  to  exposure 
to  the  violet  and  chemical  rays  of  the  sun  and  not  merely 
to  heat.  In  health  such  exposure  in  moderation  causes 
bronzing  of  a  reddish  brown  tint  without  any  separation 
of  the  cuticle,  and  this  colouring  in  the  open  may  be 
taken  as  an  indication  of  vigour  and  a  satisfactory 
condition  of  the  blood,  especially  as  regards  haemoglobin, 
as  it  is  this  which  protects  the  tissues  and  supplies  the 
pigment  in  a  sunburnt  skin. 

The  effect,  however,  is  different  in  those  who  are 
anaemic  or  cachectic,  in  such  as  are  accustomed  to  live 
indoors  or  in  cities,  or  where  parts  of  the  body,  usually 
covered,  are  exposed.     Under  these  circumstances,  par- 


68  Sun  Eczema 

ticularly  in  fair  subjects,  when  no  protection  is  afforded 
by  perspiration,  the  skin  scorches  quickly,  and  becomes 
red,  swollen,  hot  and  extremely  tender,  smarting  on  the 
application  of  water  or  even  with  its  natural  moisture. 
Some  degree  of  fever  is  excited,  producing  restlessness  at 
night.  In  severe  cases  blebs  form  by  exudation  beneath 
the  cuticle ;  and  in  loose  cellular  tissue,  as  in  the  face, 
the  combination  of  swelling  and  bullae  may  quite  close 
the  eyes,  causing  serious  inconvenience  and  discomfort. 
The  worst  cases  occur  on  the  water  or  on  snow,  where  both 
the  direct  and  reflected  rays  of  the  sun  have  free  access 
to  the  unprotected  skin,  which,  in  addition,  may  be  further 
denuded  of  moisture  by  a  dry  wind.  Mountain-climbers 
above  the  snow-line,  and  young  men  making  the  most 
of  a  few  days'  holiday  from  city  life,  are  the  most  frequent 
sufferers,  but  occasionally  travellers  newly  arrived  in  a 
tropical  climate  and  neglecting  reasonable  precautions 
are  the  victims. 

People  with  dark  skins  are  less  prone  to  sunburn,  and 
in  some  individuals  an  outbreak  of  closely  aggregated 
raised  red  spots  which  smart  and  itch  intolerably  takes 
the  place  of  the  more  diffused  redness,  especially  on  the 
back  of  the  hand. 

Parts  of  the  skin  which  have  become  affected  suffer 
more  readily  on  subsequent  exposure,  and  in  the  course 
of  twenty-four  or  forty-eight  hours  the  cuticle  is  shed  in 
ragged  patches  as  after  scarlet  fever,  the  surface  remaining 
sore  till  the  process  is  complete.  Apart  from  securing 
protection  from  the  direct  rays  of  the  sun,  especially  when 
first  exposed,  the  skin  should  be  kept  moist  either  by 
encouraging  some  perspiration  or  applying  a  solution 
of  glycerine,  as  it  is  only  a  dry  skin  that  burns.  Bad 
sunburn  may  require  the  application  of  Goulard  lotion, 
and  even  the  pricking  of  blisters ;  the  less  severe  forms 
are  relieved  by  diluted  glycerine  or  grease,  to  protect 
the  skin  from  the  air. 


Freckles  69 

Freckles  (Ephelides).— Fair  skins  are  most  com- 
monly affected,  and  especially  those  associated  with 
auburn  hair.  The  buff,  brown,  or  greenish  pigment  spots 
occur  in  adolescents  on  exposed  portions  of  the  skin, 
usually  the  hands  and  face.  They  may  be  sparse, 
abundant,  or  confluent,  and  individually  are  circular  or 
irregular  in  outline.  They  appear  round  the  orifices  of 
ducts  or  hairs,  principally  in  the  summer,  but  only 
partially  disappear  in  winter.  They  seem  to  take  the 
place  of  the  more  usual  bronzing,  diminishing  in  middle 
life  and  disappearing  in  old  age. 

Colin  has  demonstrated  true  melanin  in  circumscribed 
portions  of  the  basal  layer  of  cells  of  the  rete  Malpighii 
with  a  few  pigment  granules  in  the  papillary  layer. 
Sometimes  more  extensive  patches  of  pigment  occur  in 
place  of  the  freckles,  but  they  both  come  under  the  de- 
finition Actinic  Melanoses — that  is,  pigmentary  disorder 
due  to  the  chemically  active  rays  of  the  sun  unassociated 
with  heat  or  inflammation,  but  dependent  on  personal  and 
family  susceptibility  and  equally  common  in  both  sexes. 

Very  similar  pigmentation  in  the  first  two  years  of 
life  may  be  the  precursor  of  the  grave  disorder  xerodermia 
pigmentosa,  and  when  affecting  covered  parts  (lentigines 
of  Crocker)  in  elderly  people,  they  may  be  part  of  general 
degenerative  changes. 

When  few  in  number,  freckles  or  pigmented  patches 
may  be  touched  with  carbolic  acid  or  treated  by  galvano- 
puncture,  but  more  extensive  areas  should  be  covered 
with  dilute  peroxide  of  hydrogen  solution  or  oxychloride 
of  bismuth  ;    the  following  is  Unna's  formula  : 

^.  Bismuthi  Oxycliloridi      .        ,                 •      §  j 
Calomel gi'-  u 

Hydrogen.  Peroxidi  (10  vol.  solution)    .  fl.  §  j 
Adipis  lanss  et  Vaselini  .        .        aa  5  iv 

The  wearing  of  a  red  or  brown  veil  has  been  suggested, 


70  Chilblains 

to  cut  off  the  violet  and  ultra-violet  rays  in  some  degree. 
Other  formulae  are  : 

Aqua  Cossietica  Orienialis. 
^.  Bismuth.  Trinitratis,  5ij  ^.  Hydrargyri  Perchloridi,  §j 

Hydrargyri  Ammoniati,  3ij  Aquse  destillate,  §iv 

Adipis  prEeparatse,  5]  Ovorum  sxiv  albumen 

To  be  spread  on  lint  and  laid  Succi  citri  (i.e.  Malse  Medicae), 

on  the  patches  at  night.  §  iij 

Sacchari  aibi,  §  viij 

Chilblains  (Erythema  Pernio). — It  is  reckoned 
one  of  the  beneficent  properties  of  memory  that  pleasant 
impressions  are  retained  longer  and  with  greater  vividness 
than  those  of  a  disagreeable  nature.  Perhaps  it  is  on 
this  account  that  the  suffering  caused  by  this  common 
complaint  is  apt  to  be  underrated,  for  it  occurs  with  less 
frequency  and  severity  in  adults  than  in  children  ;  even 
those  who  have  suffered  most  severely  in  youth 
finding  it  more  tolerable  as  they  attain  maturity.  In 
children,  however,  the  frequency  and  severity  of  the 
affection  deserve  more  attention  than  they  commonly 
receive. 

Four  phases  may  be  recognised.  Intense  itching 
accompanies  the  evening  rise  of  temperature  between 
six  and  nine  p.m.,  which  may  be  so  exasperating 
as  to  produce  a  state  of  continuous  nervous  rigor  and 
totally  prevent  application  of  any  kind,  with  the  common 
sequel  during  school-days  of  punishment  for  deficient 
preparation  of  the  morrow's  tasks.  At  the  same  time 
injury  is  done  to  the  ill-nourished  skin  by  rubbing  and 
scratching,  or  the  still  more  heroic  measures  of  beating 
with  brushes  or  holly  leaves,  or  the  application  of  irritant 
or  bhstering  agents,  not  uncommon  among  schoolboys. 

With  the  subsidence  of  the  itching  there  follows  a 
period  of  acute  tenderness  due  to  congestion  and  swelling 
of  the  affected  parts,  so  that  where  the  feet  are  affected, 
as  is  commonly  the  case,  walking  is  almost  impossible, 
and  the  patient  is  unable  to  resume  his  discarded  shoes, 


Chilblains  71 

Relief  occurs  in  the  horizontal  position,  and  with  the 
more  general  distribution  of  the  blood  as  the  child  gets 
warm  in  bed,  though  for  a  time  at  least  pain  or  itching 
may  prevent  sleep. 

Another  period  of  tenderness  rather  less  acute  attends 
first  setting  the  feet  to  the  ground  in  the  morning,  and 
the  putting  on  of  boots  is  sometimes  a  tearful  proceeding. 

Dull  aching  with  frequent  reminders  of  local  tenderness 
persist  through  the  day,  making  active  exertion  distasteful 
and  converting  to  a  painful  ordeal  "  the  sports  and 
pleasures  of  the  child." 

Thus  a  vicious  circle  is  created — chilblains  leading 
to  inactivity,  and  inactivity  in  turn  leading  to  the  per- 
sistence and  extension  of  chilblains — which  may  continue 
for  weeks,  till  a  change  of  atmosphere  or  surroundings 
brings  temporary  or  permanent  relief. 

Unfortunately,  the  immediate  suffering  does  not 
represent  the  full  extent  of  the  damage,  for  not  only  are 
the  affected  areas  extremely  liable  to  subsequent  attacks, 
when  circumstances  favour  them,  but  their  recurrence 
and  persistence  induce  thickening  of  deeper  structures, 
such  as  the  bones  and  ligaments,  particularly  about  the 
knuckles,  which  permanently  affect  the  symmetry  of 
the  fingers. 

This  indicates  that  the  complaint  is  not  merely  a 
cutaneous  affection,  and  there  are  other  considerations 
which  show  that  it  is  not  an  absolutely  local  disease. 

Sir  A.  E.  Wright  in  The  Lancet,  January  30,  1897, 
associates  local  serous  exudation  with  defective  blood 
coagulability,  including  under  this  state  urticaria  and 
chilblains.  In  ten  of  the  latter  class  of  cases  investigated, 
the  time  required  for  blood  coagulation  averaged  9  instead 
of  the  normal  3-5  minutes  ;  and  the  administration  of 
calcium  chloride  in  10-30  grain  doses  three  times  a  day 
was  attended  with  definite  improvement,  in  some  witlj 
§liortening  of  the  blood  coagulation  tirae. 


72  Chilblains 

In  early  life  other  forms  of  exudation  are  common, 
including  the  hsemophilic  constitution,  epistaxis,  and  the 
lymphatic  state  with  water-logged  tissues,  which  are 
amenable  to  the  same  treatment. 

But  the  essential  cause  of  chilblains  is  the  contraction 
of  the  terminal  arteries  under  the  direct  influence  of  cold 
in  those  whose  vasomotor  system  is  active  and  susceptible, 
and  occurs  especially  in  those  who  display  this  vaso- 
motor excitability  in  other  ways,  such  as  ready  blushing 
and  sweating — the  nervous-sanguine  temperament  of 
older  writers.  The  majority  of  people  do  not  display 
this  peculiar  susceptibility,  and  it  undoubtedly  diminishes 
with  age. 

The  effect  of  vasomotor  contraction  is  to  cut  off  the 
blood  supply,  and  in  a  proportionate  degree  the  vis  a 
tergo,  from  the  periphery  of  the  circulatory  area,  which 
then  cools  down  under  the  influence  of  low  temperature, 
while  the  corresponding  capillary  areas,  where  most 
exposed  or  subjected  to  extra  cold  or  pressure,  become 
exsanguine. 

These  are  the  patches  which  under  the  restored 
pressure  of  the  circulation  undergo  capillary  dilatation 
and  blood-stasis  with  the  accompanying  phenomena  of 
inflammation — heat,  redness,  swelling  and  pain,  or 
itching,  and  which  are  extremely  prone  to  relapse  after 
recovery  if  again  exposed  to  a  low  temperature. 

Such  patches  commonly  occur  over  the  inner  and 
outer  sides  of  the  hands  and  feet,  on  the  knuckles,  heels, 
and  ball  of  the  foot,  and  even  on  the  nose  and  ears.  A 
more  unusual  spot  is  the  vertex  of  the  bald  head,  and  in 
the  days  of  our  grandmothers  and  the  thin  Empire 
costume  it  was  not  unknown  for  chilblains  to  extend 
beyond  the  feet  some  way  up  the  front  of  the  shins. 

The  effect  of  low  temperature  on  the  vasomotor 
system  is  much  enhanced  by  extremes  of  humidity  and 
dryness  of  the  air,  and  most  people  are  familiar  with  th^ 


Prevention  of  Chilblains  73 

striking  penetration  of  cold  associated  with  the  dryness 
of  an  east  wind  or  the  wet  of  a  partial  thaw. 

The  effect  of  local  pressure  is  sufficiently  illustrated 
by  the  prominent  spots  which  chilblains  select,  and  by 
the  experience  of  wearing  tight  and  thin  gloves  or  boots 
in  cold  weather. 

Erythema  pernio  has  affinities  with  erythema  nodo- 
sum and  Raynaud's  disease  and  is  defined  by  Galloway 
in  AUbutt's  System  of  Medicine  as  a  "  subacute  variety 
of  erythema  of  the  angioneurotic  kind,"  and  is  specially 
associated  with  the  susceptible  arteries  of  youth,  and 
sometimes  with  feeble  circulation,  as  evidenced  by  an 
over-slow  or  over-rapid  pulse.  The  local  changes  are, 
first,  contraction  of  the  capillary  areas  through  the  effect 
of  cold  on  the  over-active  neuro-muscular  vascular 
system,  manifested  by  pallor,  shrinking,  and  numbness  ; 
second,  vascular  reaction  or  erythema ;  and  third,  if  the 
depressing  influence  has  been  sufficiently  severe,  paralysis 
with  persistent  dilatation  of  the  venous  capillaries  and 
venules  of  the  part,  with  escape  of  serum  and  even  blood 
from  the  vessels,  causing  oedematous  swelling  of  the  cutis 
and  loosening  of  the  epidermis,  which  is  easily  injured 
or  removed,  though  the  formation  of  bullae  is  rare. 
Abrasion  of  the  surface  causes  shallow  ulceration  which 
is  slow  to  heal  on  account  of  the  poorly  nourished  state 
of  the  tissues,  while  further  septic  infection  may  involve 
extension  in  depth  and  area. 

The  prevention  of  chilblains  in  those  who  are  sus- 
ceptible is  in  short  the  avoidance  of  cold.  Such  subjects 
must  be  warmly  clad  throughout — the  body,  to  secure 
the  main  sources  of  heat ;  the  limbs,  to  ensure  sufficient 
supply  of  heat  and  blood  to  the  extremities,  for  it  is 
chiefly  in  the  wrists  and  ankles  that  the  main  vessels  are 
most  exposed  to  the  contracting  influence  of  cold  ;  and 
the  extremities  themselves,  as  the  most  vulnerable  parts. 
In  addition  to  the  clothing  usually  worn,  long  worsted 


74  Remedies 

sleeves  and  cloth  or  leather  gaiters  or  high  boots  should 
form  part  of  the  costume  in  cold  weather.  Gloves  and 
boots  should  be  large  so  as  to  fit  loosely  and  allow  of 
linings  or  thicker  hose.  Some  people  find  worsted  next 
the  skin  provocative  of  the  malady,  and  in  such  it  should 
be  worn  over  a  smoother  material,  or  two  pairs  of  socks 
may  be  employed,  provided  they  do  not  involve  any 
pressure  on  the  feet. 

The  now  prevalent  and  wholesome  custom  of  per- 
forming certain  muscular  evolutions  and  exercises  on 
rising  or  after  the  morning  bath  is  to  be  encouraged. 
In  any  casfe,  it  is  essential  to  begin  the  day  warm  and 
vigorous.  To  draw  cold  garments  over  cold  hmbs  and 
descend  without  energy  to  breakfast  in  an  ill-warmed 
room,  and  then  perhaps  to  start  on  a  cold  journey  without 
any  definite  effort  to  rouse  the  circulation,  is  to  court 
not  only  chilblains,  but  more  serious  maladies.  It  is 
this  chilly  and  sedentary  beginning,  so  foreign  to  youthful 
nature,  which  makes  so  many  victims  in  school-days, 
when  children  should  either  enjoy  proper  warmth  or  be 
free  to  rouse  their  energies  in  their  own  turbulent  fashion. 

When  chilblains  have  once  become  eatabhshed,  their 
cure  is  not  an  easy  matter ;  even  relief  is  difficult  to 
secure,  as  witnessed  by  the  number  and  variety  of  remedies 
recommended.  As  is  the  case  in  many  similar  instances, 
these  are  mostly  objectionable  or  ineffective.  Anything 
which  involves  rubbing  the  affected  skin  or  which  causes 
it  to  become  sodden  tends  to  make  matters  worse  by 
injuring  the  already  damaged  epidermis,  while  a 
continuous  application  of  any  kind  to  the  extremities  is 
more  inconvenient  and  disabling  than  the  complaint  itself, 
so  that  few  remedies  get  a  fair  trial,  and  the  effect  of 
intermittent  applications  is  usually  discounted  by  fresh 
exposure  to  cold  during  the  day. 

Taking:  these  considerations  into  account,  the  most 
practical  means  of  dealing  with  the  situation  is  first  to 


Treatment  of  Chilblains  75 

secure  proper  warmth  by  suitable  clothing  and  exercise, 
taking  care  to  change  or  dry  moist  garments,  especially 
foot  covering,  in  the  evening  ;  and  to  reserve  for  the  night 
the  application  of  more  definite  remedies. 

For  the  relief  of  the  intolerable  itching  which  usually 
occurs  in  the  evening  nothing  is  so  immediately  effective 
as  heat.  Roasting  the  chilblain  before  the  fire  to  the 
limit  of  endurance  and  repeating  the  process  several 
times  will  allay  the  itching  at  the  moment,  and  if  per- 
severed with  will  ultimately  effect  a  cure.  Another  plan 
is  to  steep  the  hand  or  foot  in  very  hot  water,  removing 
it  when  the  scalding  can  no  longer  be  borne,  and  either 
letting  it  cool  in  the  air  or  plunging  it  momentarily  into 
cold  water,  repeating  the  hot  immersion  several  times. 
If  the  skin  is  then  carefully  dried  without  rubbing,  the 
cuticle  does  not  suffer,  but  this  method  is  not  suited  to 
broken  chilblains.  Afterwards,  or  when  going  to  bed, 
a  solution  of  lead  acetate  in  spirit  or  eau  de  Cologne  may 
be  applied,  or  an  ointment  composed  of  two  drachms 
of  wintergreen  oil  in  an  ounce  of  lanoline.  In  either 
case  the  addition  of  menthol  in  the  proportion  of  15 
grains  to  the  ounce  will  be  soothing,  if  there  is  much 
tenderness  or  itching  ;  or,  a  dusting  pov/der  composed  of 
Boric  Acid  50,  powdered  Talc  25,  Starch  25,  with  a  Httle 
Camphor  or  Menthol ;  or  Calamine  7,  Menthol  1,  may  be 
used.  Relief  has  followed  steeping  the  chilblains  for  five 
minutes  in  a  solution  of  alum,  one  teaspoonful  to  a  gallon 
of  hot  water.  Many  other  applications  have  been  recom- 
mended, such  as  castor  oil,  tincture  of  iodine,  and  a  lotion 
containing  an  ounce  each  of  hquor  plumbi,  tincture  of 
opium,  and  glycerine  in  eight  ounces  of  water;  but  these 
applications  may  be  considered  to  come  under  the 
criticism  previously  expressed  ;  even  wintergreen  oil  is 
distinguished  by  an  odour  which  is  so  penetrating  and 
enduring  as  to  render  frequent  repetition  undesirable, 
but  if  used  as  an  ointment  and  either  lightly  rubbed  i^ 


76  General  Measures 

or  covered  with  socks  or  gloves,  this  is  less  developed, 
and  its  beneficial  influence  compensates  for  the  disad- 
vantage, otherwise  Mesotan  or  Kasemol  may  be  substi- 
tuted. Whatever  preparation  is  employed,  it  is  probable 
that  the  uniform  warmth  derived  from  the  bathing,  and 
covering  for  several  hours  at  a  time,  has  much  to  do 
with  the  improvement. 

For  cleanliness  and  efficiency  probably  no  remedy 
can  vie  with  the  Faradic  current,  applied  either  by 
pads  or  the  water  bath,  according  to  the  amount  of 
surface  involved,  the  best  effect  being  produced  when 
both  poles  are  applied  to  the  chilblain,  but  this  is  not  a 
method  that  is  generally  available. 

As  in  applying  treatment  for  a  cold  in  the  head,  the 
course  of  the  malady  is  so  variable  in  different  subjects, 
and  in  the  same  one  on  different  occasions,  besides  being 
powerfully  modified  by  changes  in  the  atmospheric 
conditions,  that  its  effect  is  difficult  to  estimate. 

Apart,  however,  from  local  treatment,  it  appears  that 
the  adoption  of  more  liberal  diet  with  some  stimulant 
and  tonic,  such  as  phosphate  of  iron,  to  meet  the  depressing 
influence  of  the  cold,  damp,  and  darkness  of  the  winter, 
is  decidedly  beneficial.  In  Raynaud's  disease  great 
benefit  results  from  the  administration  of  vascular  dilators 
such  as  nitroglycerine  or  the  nitrites  of  soda  or  ether, 
and  by  analogy  these  might  be  expected  to  prove  beneficial 
where  contraction  of  the  peripheral  circulation  occurs 
from  exposure  to  cold,  combined  where  necessary  with  a 
cardiac  tonic. 

In  the  case  of  broken  chilblains  great  cleanliness 
should  be  observed,  and  an  omtment  applied  consisting 
of  5  per  cent,  carbolic  acid  in  vaseline  or  the  more 
complex  one  recommended  by  Unna :  Resorcin  5 
or  Ichthyol  5,  Salicyhc  Acid  3,  Soft  White  Paraffin  to 
100.  Where  the  skin  is  only  threatening  to  give  way, 
9,  covering  of  flexible  coUodjon  may  save  it, 


Whitlow  77 

Whitlow  (Paronychia). — Suppurative  inflamma- 
tion of  the  finger  ends  has,  under  this  term,  included  disease 
spreading  to  various  structures,  including  the  synovial 
sl'ieaths  and  the  deep  tissues  of  the  arm,  involving  loss 
of  use  or  actual  sacrifice  of  the  limb.  Only  the  superficial 
forms,  however,  will  be  considered  here,  such  indeed 
as  are  limited  to  the  region  immediately  beneath  the 
epidermis  or  nail.  The  most  obvious  characteristic 
is  the  presence  of  a  white  central  patch  due  to  a  small 
collection  of  pus  beneath  the  cuticle,  either  alongside  or 
beneath  the  nail  or  at  a  little  distance  from  it  on  the 
terminal  phalanx  of  the  finger  or  toe,  with  an  area  of 
redness  round  it. 

A  focus  of  this  kind  resulting  from  the  inoculation  of 
septic  matter  by  scratch  or  puncture  is  usually  single, 
limited  in  area,  and  attended  by  severe  throbbing  pain. 
It  will  extend  if  left  alone,  but  immediately  the  pus  is 
released,  relief  occurs  and  recovery  is  rapid.  There  is 
always  an  antecedent  period  of  twenty-four  hours  or 
perhaps  more  before  pus  can  be  detected,  during  which 
pain  may  be  increasingly  acute  and  is  best  treated  by  a 
hot  or  cold  compress  with  a  few  drops  of  laudanum,  the 
hand  being  elevated.  This  treatment  may  be  continued 
after  pricking  or  snipping  the  raised  cuticle,  but  the 
separated  portion  should  be  completely  removed,  the 
underlying  surface  thoroughly  cleansed  and  then  protected 
by  an  emollient  ointment  till  sound.  When  the  inflam- 
mation extends  beneath  the  nail  to  any  extent,  recovery 
will  not  be  complete  till  this  has  either  separated  by 
itself  or  been  removed,  but  while  only  at  the  edge,  the 
nail  may  be  saved  if  the  pus  can  find  an  exit,  and  the 
part  be  soaked  with  an  effective  antiseptic  such  as 
corrosive  sublimate  solution  1  to  1000,  having  been 
previously  anaesthetised  with  eucaine,  as  much  pain 
is  excited. 

When    paronychia    develops    in    children    who    are 


78  Warts 

debilitated,  and  not  infrequently  suffering  from  pustules, 
the  affection  is  more  widespread,  involving  more  than 
one  finger  and  generally  both  hands.  The  pain  is  not 
so  great  and  the  affection  runs  a  more  chronic  course.  It 
is  best  treated  then,  as  part  of  the  pustular  eczema, 
with  white  precipitate  ointment  and  tonics,  not  neglecting 
to  evacuate  pus  and  expose  the  diseased  part  to  the 
antiseptic. 

Warts  (Veppuea)  are  small,  rough,  and  compara- 
tively insensitive  projections  from  the  skin  occurring  prin- 
cipally on  the  hands  and  face  or  scalp — that  is,  on  parts 
unprotected  by  clothing — in  young  people  ;  though  later 
in  life  they  are  more  often  met  with  on  covered  parts, 
especially  the  back.  When  very  numerous,  flattened 
and  pigmented,  in  persons  past  middle  life  they  are 
sometimes  associated  with  or  appear  to  be  the  forerunners 
of  mahgnant  disease  of  the  viscera,  as  in  the  disease 
known  as  acanthosis  nigricans,  though  they  may  ac- 
company other  complaints  such  as  eczema  or  leuco- 
cythsemia. 

The  sporadic  form,  occurring  commonly  enough 
singly  or  in  groups,  may  assume  various  individual 
shapes,  being  flat,  irregularly  peaked,  or  filiform.  Warts 
are  unsightly,  particularly  when  discoloured  by  the 
accumulation  of  dirt  in  their  interstices,  and  are  apt  to 
bleed  or  become  painful  from  time  to  time  owing  to 
slight  injury.  They  persist  for  months  or  years,  grow- 
ing in  size  as  well  as  becoming  more  numerous  by  the 
development  of  fresh  ones  in  the  vicinity,  though  they 
may  at  any  time  disappear  spontaneously. 

A  wart  consists  of  either  a  papilla  or  projecting  core 
of  the  skin  containing  a  small  artery  and  overlaid  with 
a  rugged  accumulation  of  corneous  cells  derived  from 
overgrowth  of  the  epidermis. 

Colrat  of  Lyons  has  reported  cases  in  which  the 
warts   have   dropped   off   under   general    treatment   by 


Remedies  for  Warts  79 

sulphate  of  magnesia,  two  or  three  grains  in  children  and 
haK  a  drachm  in  adults  being  given  three  times  a  day. 
Crocker  confirms  this,  and  also  suggests  full  doses  of 
nitro-hydrochloric  acid  or  thirty  to  sixty  minims  of  the 
tincture  of  thuya  occidentalis  (arbor  vitas)  two  or  three 
times  a  day.  One  or  other  of  these  drugs  may  be  em- 
ployed where  the  warts  are  very  numerous,  or  tend  to 
recur,  but  where  there  are  only  a  few,  local  measures 
suffice  and  are  more  speedy.  Perhaps  the  most  powerful 
escharotics  are  either  nitric  acid  or  the  acid  nitrate  of 
mercury,  applied  very  sparingly  to  the  rugged  surface 
with  a  glass  rod  or  the  end  of  a  wooden  match.  The 
fluid  permeates  the  cuticle  and  gradually  affects  the 
core  of  true  skin,  completely  and  permanently  destroying 
the  growth.  Both  these  remedies  have,  however,  the 
disadvantages  of  discolouring  the  surface  temporarily, 
causing  pain  in  proportion  to  the  freedom  with  which 
they  are  applied,  and  leaving  a  perceptible  scar,  which 
may  be  objectionable  on  the  scalp  or  face.  Less  drastic 
remedies,  which  are  nevertheless  effective  if  less  speedy, 
are  Hquefied  carbolic  acid,  ethylate  of  sodium,  caustic 
potash  or  soda,  chromic  acid,  glacial  acetic  acid,  per- 
chloride  of  iron,  liquor  plumbi  subacetatis,  and  a  saturated 
solution  of  salicyhc  acid  in  alcohol.  If  the  caustic 
alkahs  are  used,  it  is  well  to  protect  the  surrounding  skin 
with  wax  or  paraffin,  as  they  are  liable  to  spread,  and 
while  applying  the  remedy  a  piece  of  blotting-paper 
should  be  held  ready  to  mop  up  any  excess.  Chromic 
acid  is  best  employed  on  the  bare  face  of  the  papilla 
after  removing  the  horny  layer  by  the  previous  applica- 
tion of  sahcyLic  acid  in  solution  or  plaister.  Sodium 
ethylate  is  prepared  by  dissolving  one  part  of  metallic 
sodium  in  twenty  parts  of  absolute  alcohol,  the  vessel 
being  cooled  by  immersion  in  a  stream  of  water,  and 
should  be  applied  once  daily  for  three  or  four  days  in 
succession.     It  causes  no  pain,  and  the  eschar  drops  off 


8o  Corns  and  Callosities 

of  itself.  The  preparation  recommended  by  Kaposi 
consists  of  Sulphur  5  v,  Glycerine  5  i|,  and  Acetic  Acid 
5  ii|.  It  should  be  applied  daily.  Filiform  warts 
occurring  on  the  face,  and  especially  the  eyelids,  are 
most  speedily  obliterated  by  snipping  off  flush  with 
the  skin  and  applying  the  nitrate  of  silver  point  to 
the  base.  Thin  flat  ones  may  be  accounted  for  by 
frequent  application  of  the  alcoholic  solution  of 
salicylic  acid  alone,  while  the  larger  pedunculated  forms 
are  best  disposed  of  by  the  galvanic  ecraseur  or  they 
may  be  snipped  off  and  the  bleeding  stopped  with  pressure 
and  styptics  or  the  cautery. 

Corns  and  Callosities. — It  was  one  of  the  axioms 
of  John  Hunter  that  pressure  from  within  caused  atrophy 
and  pressure  from  without  hjrpertrophy,  and  the  develop- 
ment of  corns  and  callosities  was  regarded  as  a  famiUar 
example  of  the  latter.  The  modern  interpretation  is 
broader,  regarding  constant  pressure  as  the  cause  of 
atrophy  and  intermittent  as  that  of  hypertrophy.  In 
the  subject  under  consideration,  intermittent  pressure 
associated  with  the  expansion  of  the  arches  of  the  foot 
as  it  receives  the  weight  of  the  body  at  each  step,  and 
the  limitation  of  the  boot,  accounts  for  these  develop- 
ments ;  hard  corns  over  bony  projections,  callosities  of 
a  more  diffuse  form  over  yielding  parts,  and  soft  corns 
in  moist  places,  as  between  the  toes,  being  the  rule. 

In  places  not  specially  exposed  to  pressure  an  ac- 
cumulation of  the  epidermis  closely  resembling  a  corn 
is  sometimes  due  to  a  foreign  body,  such  as  a  splinter 
of  wood  or  glass  or  a  thorn,  lodged  below  the  surface. 
The  development  of  corns  may  be  prevented  by  wearing 
properly  fitting  boots  which  aUow  space  for  the  normal 
expansion  of  the  plantar  arches  in  walking  or  standing, 
and  the  natural  enlargement  of  the  foot  in  warm  weather. 
Merely  loose  boots  are  not  necessarily  satisfactory,  since 
they  are  apt  to  exert  pressure  nowhere  but  on  the  pro- 


Corn  Cures  8i 

jecting  points  where  corns  especially  form.  The  practice 
of  not  wearing  the  same  pair  on  consecutive  days,  leaving 
them  on  boot-trees  in  the  interval,  is  a  good  one,  and 
those  who  suffer  would  do  well  to  avoid  keeping  boots 
on  unnecessarily.  The  spontaneous  cure  of  corns  when 
boots  are  dispensed  with,  as  during  a  sea  voyage  or 
illness  of  two  or  three  weeks'  duration,  is  very  striking. 

The  pain  associated  with  the  presence  of  a  corn  is 
increased  in  very  dry  or  with  the  onset  of  wet  weather, 
owing  to  the  increased  hardness  of  the  epidermis  exerting 
more  concentrated  pressure  on  the  underlying  nerves 
in  the  one  case,  and  the  increased  vascularity  of  the 
superficial  tissues  in  the  other.  But  in  addition  to 
exacerbations  with  atmospheric  changes,  increase  of  pain 
may  result  from  inflammation,  or  effusion  or  suppuration 
in  a  small  bursa  formed  beneath  the  hardened  skin. 

Immediate  relief  from  pain  can  usually  be  secured  by 
the  removal  of  pressure,  and  this  is  most  easily  effected  by 
surrounding  the  projection  with  a  ring  of  wool  attached  by 
gum :  the  corn-plaisters  commonly  supplied  are  too  clumsy, 
and  a  more  satisfactory  ring  can  be  made  by  cutting  it  out 
of  the  raw  material,  and  if  necessary  reducing  it  in  thick- 
ness. This  method  is  quite  physiological,  equally  adapted 
for  hard  or  soft  corns,  and  if  persisted  with  will  effect  a 
complete  cure.  Subsequent  recurrence  may  be  prevented 
by  the  application  of  soap,  or  diachylon  plaister. 

The  removal  of  the  thickened  epidermis  may  be  more 
speedily  effected  by  careful  cutting  after  soaking  in  hot 
water,  or  by  painting  twice  a  day  with  a  solution  of 
salicylic  acid,  the  formula  recommended  by  Vigier  being 
a  very  good  one  : 


Acid.  Salicylic.    .        , 

.        .      gr.  XV 

Ext.  Cannab.  Ind. 

.     gr.  viij 

Alcohol.      .         ,        , 

.            .            Til  XV 

Etheris 

.            .            Til   xl 

Collodion,  Flexil. 

.        .    ni  Ixxv 

82  Bunion 

If  this  be  continued  for  a  week,  the  corn  will  faU  off  of 
itself,  but  may  leave  the  underlying  skin  pink,  thin,  and 
tender  for  a  day  or  two. 

An  inflamed  corn,  whether  suppurating  or  not,  must 
be  treated  with  a  cold  wet  compress  for  twelve  hours  at 
least,  preferably  through  the  night,  to  reduce  the 
tenderness  before  it  can  be  removed,  or  the  lotion  of 
lead  acetate  and  opium  may  be  used  instead.  It  is  not 
usually  difficult  or  very  painful  to  loosen  the  periphery, 
which  is  softer  and  generally  more  raised  than  the  harder 
centre,  but  the  final  separation  demands  more  fortitude. 
When  suppuration  has  occurred,  the  difficulty  is  rathw 
diminished,  as  there  is  a  cavity  beneath  the  corn  com- 
municating with  the  surface  usually  at  the  edge,  and 
by  extending  this  with  fine-pointed  scissors  a  radical 
cure  can  be  effected,  though  the  tender  area  needs  pro- 
tection from  pressure  for  some  days. 

The  essential  point  in  the  cure  of  soft  corns  is  relief 
from  pressure  and  moisture,  the  former  by  a  small  felt 
ring,  and  the  latter  if  necessary  by  the  use  of  oxide  of 
zinc  powder  or  alum,  but  the  mere  separation  of  contiguous 
surfaces  is  generally  sufficient. 

Bathing  the  feet  in  cold  water  in  the  evening,  and 
putting  on  dry  hose  after  exertion,  is  not  only  refreshing, 
but  an  excellent  preventive  of  both  soft  corns  and  blisters. 

Bunion. — This  is  commonly  regarded  by  the  laity 
as  an  exaggerated  corn,  though  it  is  of  course  much  more, 
but  finished  off  with  much  thickening  of  the  cuticle  over 
the  most  prominent  part.  It  is,  in  fact,  a  subluxation 
outwards  of  the  metatarso-phalangeal  joint  of  the  hallux, 
with  overgrowth  of  the  base  of  the  phalanx,  this  being 
overlaid  by  a  bursa  which  inflames  at  intervals,  capped 
by  thickened  epidermis.  There  is  always  a  large  branch 
of  the  long  saphenous  nerve  involved  in  the  bursa,  and 
the  vascular  supply  is  generous.  As  this  particular  joint 
is  freely  exposed  to  injury,  and  is  moreover  the  favourite 


Ingrowing  Toenail  83 

seat  of  acute  and  chronic  gout,  besides  having  powerful 
muscles  attached  to  the  movable  part,  the  arrangements 
from  the  point  of  view  of  torture  are  as  complete  as 
possible.  The  radical  cure  of  such  a  condition,  when 
fully  developed,  involves  operation,  and  will  not  be  entered 
into  here,  but  in  an  incipient  state  something  may  be 
done  short  of  this  to  delay  or  prevent  further  develop- 
ment and  relieve  pain. 

In  the  first  place  it  must  be  understood  that  an 
important,  if  not  the  sole  cause  of  the  condition,  is  eversion 
of  the  great  toe  due  to  wearing  pointed  shoes  with  high 
heels,  and  the  first  step  must  be  to  secure  reasonably 
shaped  boots  with  straight  inner  border  instead  of  those 
usually  selected  with  unlimited  latitude  across  the  ball 
of  the  foot,  leaving  the  malposition  of  the  hallux  un- 
corrected. If  necessary,  the  great  toe  may  be  brought 
into  its  proper  line  by  means  of  a  toe-post  or  brace. 
Temporary  inflammation  may  be  reduced  by  a  cold 
compress  or  evaporating  lotion,  and  the  corn  on  the 
inner  aspect  removed.  Wearing  a  cap  of  fairly  thick 
diachylon  plaister  over  the  projecting  part  of  the  joint 
will  afford  some  comfort  and  protection,  and  when  the 
patient  has  acquired  confidence  by  walking  under  the 
corrected  conditions  and  becomes  used  to  them  she  will 
be  in  a  fair  way  to  recovery. 

Ing-powin^  Toenail. — The  pressure  on  the  inner 
side  of  the  great  toe  has  another  effect  in  pushing  up  the 
skin  on  this  aspect  while  doubling  up  the  nail  longi- 
tudinally ;  the  inner  edge  then  buries  itself  in  the  con- 
tiguous sulcus,  and  before  long  causes  painful  pressure 
and  ulceration. 

The  remedy  for  this  disabling  state  of  affairs  is  to 
relieve  the  lateral  pressure  by  allowing  sufficient  space 
in  the  boot  for  the  toes  to  spread  naturally  in  walking, 
while  softening  and  thinning  the  convex  portion  of  the 
nail  by  soaking  it  in  hot  water  and  gradually  scraping 


84  Finger  Cracks — Blisters 

with  glass  or  a  penknife.  When  this  has  been  done 
sufficiently  to  allow  the  nail  to  yield  to  manipulation,  a 
thin  strip  of  oiled  lint  should  be  gently  packed  between 
the  buried  edge  and  the  skin  with  the  flat  end  of  a  probe. 
The  parts  having  been  sufficiently  separated  by  this 
device,  it  may  be  possible  to  insert  a  strip  of  thin  sheet 
lead  beneath  the  border  of  the  nail  and  by  carrying  it 
round  below  the  toe  to  gradually  reduce  the  prominent 
inner  border  of  skin  to  its  proper  limits.  It  is  sometimes 
necessary  to  suppress  a  fungous  outgrowth  of  granulation 
tissue  by  zinc  oxide,  red  oxide  of  mercury  or  lunar  caustic, 
or  to  adopt  the  more  heroic  method  of  avulsing  the  nail, 
and  if  it  continues  to  grow  in  a  deformed  shape  to  destroy 
the  matrix  with  carbolic  acid  or  by  erasion. 

Fing'er  Cpaeks  are  really  a  limited  form  of  eczema 
rimosum.  They  occur  most  commonly  across  the  top  of 
the  thumb,  and  recur  with  painful  regularity  in  the  same 
place  each  winter  or  spring,  generally  during  the  prevalence 
of  cold  dry  east  wind.  At  these  times  the  use  of  a  drop 
or  two  of  glycerine  rubbed  over  the  hands  while  drying 
them  after  washing  will  keep  the  skin  moist  and  supple 
and  prevent  their  formation.  The  application  of  pumice 
stone  to  the  thickened  cuticle  at  the  top  of  the  thumb 
by  reducing  its  thickness  will  also  prevent  cracking. 

The  hands  should  not  be  washed  more  frequently 
than  really  necessary  ;  very  cold  water  and  soap  containing 
much  free  alkali  should  be  avoided,  and  the  skin  should 
be  completely  dried  with  a  soft  towel,  subsequent  evapora- 
tion having  much  to  do  with  the  trouble. 

Besides  reducing  the  hard  edges  of  cuticle  with  pumice, 
zalicylic  acid  plaister  or  the  same  drug  in  collodion  may 
be  employed,  and  later  those  applications  recommended 
in  Cracked  Lip.  Constantly  wearing  a  rubber  cap  on  the 
affected  part  is  very  beneficial. 

Blisters  result  from  separation  of  the  outer  corneous 
layers  from  the  newer  and  moister  epidermal  strata  of 


Treatment  of  Blisters  85 

the  outer  skin  by  effusion  of  serous  fluid.  Apart  from 
those  caused  by  burns  or  the  application  of  vesicants,  they 
commonly  occur  in  consequence  of  unaccustomed  pressure 
or  friction  associated  with  moisture,  derived  in  most  cases 
from  perspiration.  It  is  only  in  the  palms  and  soles 
that  the  outer  layers  of  the  skin  are  sufficiently  thick 
and  coherent  to  furnish  material  for  the  dome  of  a  blister, 
pressure  and  friction  in  other  parts  leading  to  thinning 
and  abrasion  instead.  The  development  of  a  blister  is 
accompanied  with  soreness,  which  may  set  a  limit  to  the 
particular  occupation  inducing  it,  and  in  such  case  the 
formation  is  arrested  by  subsidence  of  hyperaemia  and 
absorption  of  exuded  fluid,  but  the  active  process  is 
speedily  renewed  if  pressure  and  friction  are  repeated 
within  twenty-four  hours.  On  the  other  hand,  if  sufficient 
rest  is  allowed,  a  thickening  of  the  epidermis  results, 
which  is  protective,  so  that  by  gradually  inuring  the  skin 
to  unaccustomed  pressure,  whether  in  the  use  of  the  hands 
or  feet,  the  formation  of  blisters  may  be  avoided,  and 
such  graduated  use  affords  the  best  preparation  for  any 
continued  effort. 

Should  the  irritation  be  continued  without  regard  to 
the  soreness  which  attends  the  raising  of  the  cuticle,  the 
blister  will  extend  in  area  as  well  as  in  height  and  tension, 
until  it  gives  way  at  the  margin,  discharging  the  contained 
fluid,  which  continues  to  ooze  from  the  rent  for  some 
hours.  The  worst  feature,  however,  in  a  broken  blister 
is  the  admission  of  air,  which  dries  the  new  and  tender 
layers  beneath,  causing  them  to  stiffen  and  crack  on 
movement,  thus  prolonging  the  duration  of  the  sore  and 
affording  opportunity  for  the  ingress  of  septic  matter, 
which  may  still  further  increase  the  injury  and  retard 
recovery. 

The  main  object,  then,  in  dealing  with  blisters  is  to 
prevent  if  possible  their  extension  when  they  threaten 
to  form,  or  at  all  events  to  anticipate  their  rupture,  and 


86  Staining  of  Feet 

the  exposure  of  the  young  skin  beneath,  either  by  pre- 
serving the  natural  epidermal  covering  or  by  keeping  the 
part  from  drying  and  cracking  by  the  application  of 
some  emollient  such  as  vaseline  or  simple  ointment. 

As  a  precautionary  measure  in  prolonged  marching, 
some  form  of  woollen  covering  for  the  feet  is  preferable 
to  cotton,  and  old  campaigners  recommend  soaping  the 
inside  of  socks  or  dispensing  with  them  altogether.  At 
the  end  of  the  day  bathing  the  feet  in  cold  water  is  both 
refreshing  and  preservative  of  the  skin,  and,  failing  a 
complete  change,  the  shifting  of  the  right  sock  to  the 
left  foot,  after  drying,  is  a  useful  expedient.  Walking 
with  wet  feet  is  to  court  blisters,  and  it  is  worth  some 
delay  and  inconvenience  to  avoid  this,  especially  when 
walking  day  after  day. 

Rubbing  the  skin  of  the  palms  and  soles  with  any 
form  of  spirit  tends  to  toughen  it,  and  too  frequent 
ablution  with  soap  and  water,  especially  hot  water  and 
alkaline  soap,  has  a  reverse  effect. 

If  time  cannot  be  given  to  allow  a  blister  to  subside 
of  itself,  or  if  it  is  already  too  far  advanced  to  permit  of 
this  occurring,  a  convenient  plan  is  to  pass  a  needle  and 
white  thread  through  one  edge  and  then  cut  the  thread 
close  to  the  skin,  so  that  the  ends  just  project  and  supply 
a  wick  by  which  the  contained  fluid  may  slowly  drain 
away.  This  allows  the  cuticle  to  fall  back  on  the  soft 
skin  beneath  without  admitting  air,  and  supplies  a 
practical  cure  even  if  further  effort  is  resumed.  A  bhster 
is  in  itself  a  small  matter,  but  if  neglected,  leads  to  much 
discomfort,  and  may  involve  further  trouble  through 
local  infection  and  inflammation  of  glands. 

Blue  Staining"  of  the  Feet. — During  the  hot 
weeks  of  summer  numerous  instances  have  occurred  in 
London,  and  no  doubt  elsewhere,  of  greenish  blue  indel- 
ible patches  on  the  feet  of  young  women.  The  iden- 
tification  of   the  colouring  matter  as  indigo  has  led  to 


Removal  of  Stains  87 

some  speculation  as  to  its  possible  source,  either  in 
the  action  of  some  microbe  on  the  sweat,  or  to  the 
actual  secretion  of  the  colouring  matter  in  this  product 
of  the  skin,  as  in  that  of  the  kidneys. 

There  is,  however,  no  need  to  seek  so  far  for  the  cause 
of  this  trifling  inconvenience.  Black  stockings,  so 
much  in  vogue,  owe  their  colour  to  a  process  in  which 
indigo  is  the  basis,  and  the  cheaper  materials 
undoubtedly  contain  a  large  amount  of  cotton  as  well 
as  wool. 

It  is  more  than  likely,  therefore,  that  these  blue 
stains,  so  difficult  to  get  rid  of,  are  produced  by  the  sweat 
in  very  hot  weather,  aided  perhaps  by  some  decomposition, 
removing  the  dye  from  the  material  of  the  stockings  and 
conveying  it  to  the  adjacent  cuticle. 

Though  unaffected  by  ordinary  solvents,  the  stains  are 
readily  removed  by  chlorine  water  or  a  solution  of  chlori- 
nated lime  or  soda  in  water.  They  are  only  met  with  on 
the  soles  and  sides  of  the  feet  and  toes,  more  rarely  on 
the  dorsum,  but  always  within  the  area  included  in  the 
shoes,  and  might  scarcely  be  considered  worth  troubling 
about,  except  that  those  affected  are  often  very  anxious 
to  get  rid  of  them,  and  the  cause  and  remedy  are  not 
exactly  obvious. 

Other  dyes  come  off  on  the  feet  even  more  readily, 
especially  red  aniline,  and  may  not  be  so  innocuous,  causing 
irritant  poisoning  of  abrasions  produced  by  chafing  of 
the  boots  in  hot  weather.  These  stains,  however,  are 
removed  by  prolonged  soaking  in  water,  which  is  also  the 
best  remedy  for  the  superficial  inflammation.  And  it 
is  well  not  to  resume  such  foot-covering  till  the  skin  is 
sound.  Neglect  leads  to  the  formation  of  a  chronic  and 
painful  sore,  with  inflammation  of  the  lymphatic  vessels 
and  glands.  The  employment  of  arsenic  in  dyeing  with 
red  aniline  may  have  something  to  do  with  the  irritation. 


CHAPTER    III 
THE   RESPIRATORY    SYSTEM 

Sope  Throat. — This  very  common  affection  is  due  to 
many  causes,  but  whether  it  be  the  initial  symptom  or 
be  discovered  in  the  cause  of  a  routine  examination,  it 
must  not  be  at  once  concluded  to  constitute  the  entire 
complaint.  Indeed  in  the  majority  of  cases  it  is  only 
part  of  some  general  affection  and  not,  properly  speaking, 
local  at  all. 

As  it  is  often  a  very  important,  and  in  some  cases 
a  by  no  means  easy,  matter  to  obtain  a  good  view  of  a 
child's  throat,  it  may  not  be  deemed  out  of  place  to 
suggest  the  following  method  : 

The  nurse  should  hold  the  child  in  her  lap  facing  a 
good  light,  steadying  the  head  against  her  right  shoulder 
by  embracing  it  with  her  right  arm  with  the  hand  on 
the  forehead,  while  controlling  the  hands  and  legs  with 
her  left. 

Sitting  opposite  to  her,  and  at  the  same  level,  with 
his  back  to  the  light,  the  observer  further  steadies  and 
directs  the  child's  head  by  grasping  the  nape  of  the  neck 
in  his  left  hand  with  the  thumb  in  the  right  ear.  While 
inserting  a  small  spatula  with  the  right  hand,  the  ring 
finger  carries  the  lower  lip  near  the  left  corner  of  the 
mouth  inwards  over  the  lower  gum  or  teeth,  effectually 
opening  the  mouth.  The  spatula  should  not  be  inserted 
too  far  and  should  touch  nothing  but  the  tongue.  All 
movements  should  be  gentle  and  deliberate. 

It  may  be  premised  at  the  outset,  particularly  in 

88 


Exanthemata  89 

children,  that  all  the  acute  specific  fevers  are  accompanied 
at  the  onset  by  inflammatory  affections  of  the  tonsils 
and  fauces.  To  give  instances  would  be  practically  to 
cite  the  whole  list,  but  fortunately  for  diagnosis,  other 
and  more  characteristic  features  accompany  or  speedily 
follow  the  occurrence  of  sore  throat,  and  if  the  practi- 
tioner has  been  reasonably  guarded  in  his  first  expression 
of  opinion  and  has  adopted  the  usual  antifebrile  remedies, 
the  case  will  not  have  been  prejudiced  provided  further 
careful  watch  is  kept  on  developments. 

There  is,  however,  one  exanthematic  sore  throat 
which  it  is  important  to  recognise  at  once,  both  on  the 
patient's  account  and  to  avoid  the  spread  of  infection. 
That  is  diphtheria. 

The  disease,  in  spite  of  advances  in  bacteriology  and 
serum  therapeutics,  remains  something  of  a  bugbear  on 
account  of  the  difficulty  of  diagnosis  and  the  irregularity 
and  uncertainty  of  its  course. 

There  are,  doubtless,  characteristic  features  which 
are  only  too  obvious  in  a  proportion  of  cases,  but  they 
are  so  variable  in  occurrence  and  often  delayed  so  long, 
that  the  patient  may  lose  the  advantage  of  serum  treat- 
ment, which  is  beneficial  mainly  when  administered 
within  twenty-four  hours  of  the  onset,  and  may  even 
communicate  the  disease  to  others  before  its  nature  is 
appreciated.  The  indications  specially  relating  to  diph- 
theria, some  of  which  are  pretty  sure  to  develop  in  the 
course  of  the  attack,  are  :  The  presence  of  diphtheritic 
membrane  on  the  fauces  or  in  the  expectoration,  loss  of 
knee-jerks,  and  occurrence  of  albumen  in  the  urine. 

Early  involvement  of  the  nares  or  larynx  is  also 
strongly  indicative  of  diphtheria.  More  particularly 
in  those  in  whom  dyspnoea  manifests  itself  early,  in  the 
absence  of  the  foregoing  indications,  partial  or  complete 
suppression  of  respiratory  murmur  on  one  side  of  the 
chest  or  in  one  lobe  of  the  lung  is  very  significant,  and  is 


90  Diphtheria 

a  point  to  be  very  seriously  considered,  when  meditatiag 
relief  by  tracheotomy,  indicating,  as  it  does,  deep  penetra- 
tion of  the  morbid  process  in  certain  bronchi,  which  might 
render  the  operation  useless.  The  other  general  features 
which  characterise  diphtheria  are  pallor,  prostration,  and 
an  appearance  of  profound  illness  out  of  all  proportion 
to  local  manifestations,  and  generally  associated  with 
but  slight  degree  of  fever  or  even  normal  temperature. 
One  or  other  of  these  features  will  probably  manifest 
itself  within  twenty-four  hours,  but  even  that  is  too  long 
to  wait,  and  there  are  only  too  many  instances  in  which 
no  help  to  diagnosis  is  afforded  other  than  the  finding  of 
the  Klebs-Loeffler  bacillus  or  the  late  development  of 
paralysis  either  of  the  heart,  respiration,  palate,  or  groups 
of  voluntary  muscles. 

Recognising  the  existence  of  such  cases,  beyond 
the  limits  of  immediate  certain  diagnosis,  and  the  im- 
portance of  taking  definite  therapeutic  and  protective 
measures  at  once,  many  physicians  adopt  the  practice 
of  isolation  and  the  administration  of  efficient  doses  of 
anti-diphtheritic  serum,  while  awaiting  the  report  of  the 
bacteriologist ;  and  as  neither  of  these  measures  involves 
any  serious  drawback,  should  the  case  not  prove  diph- 
theritic, comparable  to  those  resulting  from  their  omission 
if  the  reverse  is  the  case,  it  is  no  doubt  a  good  and  safe 
policy,  employed  with  reasonable  discrimination. 

It  is  not  intended  to  discuss  here  the  details  and 
treatment  of  so  serious  a  malady  as  diphtheria,  but  no 
reference  to  sore  throat  should  be  made  without  laying 
stress  on  this  important  aspect  of  the  matter. 

When  pain  or  discomfort  in  the  throat  is  complained 
of,  particularly  in  swallowing,  inflammatory  changes  can 
usually  be  recognised  in  the  soft  palate,  pharynx,  or  tonsils. 

Relaxed  Throat. — Dull  aching  with  a  sensation  of 
stiffness  and  actual  pain  in  swallowing,  and  the  sensation 
of  a  "lump  in  the  throat,"  which  repeatedly  excites  that 


Relaxed  Throat  91 

function  together  with  a  dry,  harsh,  and  painful  cough, 
usually  indicate  this  condition.  On  investigation  the 
smooth  portion  of  the  fauces,  including  mainly  the  soft 
palate,  uvula,  anterior  and  posterior  pillars,  but  to  some 
extent -also  adjacent  parts  of  the  mucous  membrane,  are 
found  to  be  unusually  red,  tense,  and  shining,  though 
in  a  later  stage  they  may  look  dull,  flabby,  or  actually 
cedematous.  The  uvula,  especially,  becomes  elongated, 
limp,  and  irresponsive  to  the  semi-voluntary  movements 
involved  in  deep  inspiration.     There  is  no  fever. 

Much  has  been  asserted  in  regard  to  the  causation  of 
cough  by  the  contact  of  such  an  elongated  uvula  with 
the  epiglottis  or  larjmx,  but  when  it  is  remembered  that  in 
the  sucking  infant  the  uvula  normally  lies  against  the 
posterior  aspect  of  the  epiglottis,  thus  providing  a  median 
channel  for  respiration,  while  the  flow  of  milk  in  suck- 
ing proceeds  on  either  side  ;  and,  further,  that  in  marine 
mammals  this  arrangement  persists  through  life  ;  con- 
tact between  the  uvula  and  epiglottis  can  scarcely  be 
looked  upon  as  an  unnatural  or  disturbing  condition. 
Hence  the  partial  or  complete  removal  of  the  uvula  is 
not  warranted  as  a  cure  for  this  temporary  state  ;  while, 
on  the  other  hand,  when  over-strenuously  performed,  it 
has  led  to  subsequent  escape  of  fluids  and  air  by  the 
posterior  nares,  and  so  to  interference  with  swallowing 
and  speaking.  Though  occasionally  revived,  this  mis- 
taken practice  has  fortunately  become  nearly  as  obsolete 
as  that  of  lancing  the  gums  to  aid  the  eruption  of  the 
teeth. 

In  either  case,  when  definite  tension  or  oedema  exists, 
superficial  scarification,  to  release  a  little  blood  or  serum, 
secures  all  the  benefit  that  can  be  obtained  by  the  use 
of  a  cutting  instrument,  and  it  is  extremely  rarely  that 
this  is  needed  at  all. 

The  condition  of  faucial  injection  is  commonly  attri- 
buted to  exposure  to  cold  moist  air,  particularly  when 


92  Rheumatic  Sore  Throat 

breathing  by  the  mouth,  and  is  more  Likely  to  occur  as 
a  local  affection  in  debilitated  subjects.  It  is  then  best 
treated  by  local  astringents  combined  with  tonics. 

Gargles  and  sprays  of  various  kinds  are  used,  but 
of  these,  gargling  with  hot  water  alone  gives  immediate 
relief,  and  subsequently  painting  the  reddened  and 
swollen  parts  with  glycerine  of  tannin  is  usually  effective. 
A  very  satisfactory  astringent  is  the  lozenge  of  Krameria 
or  of  Australian  red  gum,  which  should  be  allowed  to 
dissolve  slowly  between  the  cheek  and  the  teeth,  pre- 
cautions being  taken  against  its  being  inadvertently 
inhaled  while  coughing  or  sleeping. 

Rheumatic  Sore  Tiipoat.— If  the  fauces  be 
examined  in  any  case  of  incipient  rheumatism,  they  will 
be  found  injected,  the  mucous  membrane  appearing 
bright  red.  Not  infrequently  inflammation  extends  to 
the  tonsils,  resulting  in  follicular  or  parenchymatous 
tonsillitis,  either  of  which  may  be  a  rheumatic  mani- 
festation. 

Where  arthritis  occurs  at  the  same  time,  little  diffi- 
culty may  be  experienced  in  diagnosis,  and  under  such 
circumstances  the  condition  of  the  throat  may  even  be 
overlooked,  or  left  to  take  care  of  itself,  provided 
salicylates  are  administered  internally. 

In  the  absence  of  arthritis,  however — and  this  is 
especially  the  case  in  children — the  change  in  the  throat 
may  be  the  first  indication  except  the  general  condition 
of  fever  which  is  usually  definite  and  may  be  severe 
(105°  F.).  Indeed,  a  rapid  onset  with  high  fever  and 
tendency  to  sweating  in  a  young  child,  sometimes 
attended  by  delirium  in  the  evening,  are  the  principal 
characteristics  of  the  rheumatic  state.  It  is  very 
important,  therefore,  in  these  cases  to  examine  the  heart 
at  once  and  repeatedly,  and  to  give  salicylates  in  effi- 
cient doses,  as  either  pericarditis  or  endocarditis  may 
develop. 


Septic  Throat  93 

The  application  of  a  hot  fomentation  sprinkled  with 
half  a  drachm  of  Olei  Gaultherii,  extending  round  the 
front  of  the  neck  to  the  mastoid  region  on  each  side,  is 
at  once  a  comforting  and  curative  measure. 

Septie  Throat. — The  distribution  of  inflammatory 
changes  in  the  throat  is  very  similar  to  the  preceding, 
but  follicular  tonsillitis  is  the  prevailing  lesion  ;  there  is 
also  a  greater  tendency  to  exudation.  The  initial  fever 
is  not  80  high,  the  temperature  ascending  more  gradually, 
but  may  attain  to  103°  F.  or  more  on  the  second  or 
third  day. 

Occasional  rigors,  general  depression,  and,  locally, 
some  ulceration  are  the  leading  features.  What  is 
termed  "  an  ulcerated  throat "  is  septic,  though  the 
loss  of  tissue  is  quite  superficial  and  rarely  leaves 
any  permanent  traces.  The  circumstances  in  which 
such  a  sore  throat  occurs  may  be  some  guide  to  its 
nature. 

Many  instances  seen  among  students  in  a  hospital 
or  medical  school  are  of  this  kind,  and  recurring  attacks 
among  domestic  servants  working,  and  sometimes 
sleeping,  in  a  basement  near  sinks  and  gullies  belong 
to  the  same  category.  Most  practitioners  can  recall 
instances  where  a  recurrence  of  sore  throats  in  a  house 
has  led  to  investigation  and  attention  to  drains,  resulting 
in  complete  abolition  of  the  attacks. 

It  may  not  be  out  of  place  here  to  remark  that  drains 
require  regular  attention  and  cleansing  as  much  as 
chimneys,  though  they  do  not  always  receive  them, 
and  an  enormous  amount,  not  only  of  definite  disease, 
but  general  failure  of  health,  as  evidenced  by  loss  of 
energy  and  appetite,  anaemia  and  headache,  attacks 
of  diarrhoea,  etc.,  are  really  due  to  sewer-gas  poisoning 
from  foul  drains,  enhanced  by  insufficient  ventilation, 
both  of  the  house  and  the  drains  themselves. 

It  would  be  well  if  such  evidence  of  general  septic 


94  Treatment 

influences  were  notified  in  the  same  way  as  is  now 
compulsory  in  other  specific  diseases. 

The  treatment  of  septic  sore  throat  requires  anti- 
septics locally,  and  tonics  and  stimulants  generally. 

The  following  solution — 

^.  Hydrarg.  Perchloridi     .  ,  •     gr-  ij 

Acid.  Hydrochlorici  dil.  .  ,        5  iJ 

Glycerini        .         .         .  .  .         g  j 

Aquam  destillatam        .  .  •     .  ad  §  x 

may  be  used  every  two  hours,  either  as  gargle,  spray, 
or  for  swabbing  the  throat,  which  should  be  first  cleared 
of  secretion  by  gargling  with  a  little  hot  water. 

Care  must  be  taken  not  to  swallow  the  solution, 
and  if  any  misgiving  exists  in  regard  to  this,  it  is  better 
to  use  the  Gargarisma  Chlori. — 

^.  Potass.  Chloratis  .  ,  .  .  3] 
Acidi  Hydrochlorici  ,  .  .  ni  sij 
Aquam ad  §  x 

The  acid  and  chlorate  are  first  introduced  and  allowed 
to  react,  till  the  chlorine  gas  displaces  the  air  in  the 
bottle,  water  is  then  added  in  small  quantities  at  a 
time  tUl  the  gas  is  dissolved  ;  the  bottle  being  corked 
and  shaken  with  each  addition.  One  of  the  following 
solutions  may  be  used  :  Potass.  Permanganatis,  gr.  iv  to 
water  0.  j  ;  Formalin  solution  (40  per  cent.),  tti^j  to 
water  ^  j ;  Acetozone,  gr.  ij  to  water  5  j- 

The  best  remedies,  internally,  are  quinine,  perchloride 
of  iron,  or  biniodide  of  mercury — which  may  be  given 
as  follows  :  Mistura  Chlori.  cum  Quinina  {Burney  Yeo). 
To  Potassium  Chlorate,  in  powder,  30  grains  in  a  12- 
ounce  bottle,  add  Hydrochloric  Acid  60  minims  ;  cork 
and  shake  well  to  liberate  Chlorine ;  absorb  this  by 
gradually  adding,  and  shaking  after  each  addition, 
distilled   water    to    11    ounces ;    add    Quinine   Sulphate 


Treatment  95 

24  or  36  grains,  and  Syrup  of  Orange  ^  ]'•     Dose :  ^  j  every 
two,  three,  or  four  hours.     Other  formulae  are  : — 

'^.  Liq.  Ferri  Percblor.  it],  xv  ^.  Liq.  Hydrarg.  Perchlor.  3j 
Sp.  Chloroformi,  tn,  x  Potassii  lodidi,  gr.  v 

Glyccrini,  ui  xx  Sp.  Am.  Arom.,  int  xx 

Aquam  destill.  ad  §  j  Decoct.  Cinch,  ad  gj 

Three  times  a  day.  Three  times  a  day. 

In  the  acute  stage,  when  there  is  much  fever,  the 
following  complex  mixture  is  advocated : 


'^.  Liq.  Ferri  Perchloridi 

.    in  XV 

Liq.  Hydrarg.  Perchloridi . 

.    m  XV 

Liq.  Strychninse .... 

HI  V 

Tinct.  Aconiti     .... 

.      tniij 

Potass.  Chloratis         .        ,        , 

.      gr.  V 

Glycerini 

3i 

Aquam  destillatam     . 

.    adSj 

Three  times  a  day. 

This  is  powerfully  antiseptic  and  may  be  gargled  or 
held  in  the  back  of  the  mouth  for  a  moment  before 
being  swallowed.  It  should  not  be  continued  for  more 
than  two  days,  by  which  time  the  fever  will  usually 
have  declined.  In  all  these  prescriptions  glycerine  is 
introduced  to  prolong  the  local  effect  in  the  throat. 

Owing  to  pain  and  difficulty  in  swallowing,  nourish- 
ment must  be  given  in  liquid  or  semi-liquid  form.  Milk, 
beef -tea,  arrowroot  with  milk,  and  jelly  are  the  most 
convenient.  Fluids  taken  hot  are  comforting.  All 
applications  to  the  throat  should  be  made  subsequent 
to  taking  food,  so  as  to  prolong  their  local  effect  as 
much  as  possible. 

In  a  later  stage,  when  the  fever  and  more  acute 
symptoms  have  declined,  the  diet  must  be  liberal,  and 
a  mixture  of  quinine,  strychnine,  and  ammonia,  such  as 
the  following,  should  be  ordered  before  meals  : 

^.  Tinct.  Nucis  Vomicae    .  .  ni  v 

Tincturae  Cinch.  Co.      .  .  .  5ss 

Sp.  Ammon.  Aromat.    ,  •  .  tti  xx 

Aqaam  Chloroformi      .  .  .  ad.  gj 


96  Follicular  Pharyngitis 

This  does  not  make  a  clear  mixture,  but  it  is  a  good 
bitter  aromatic,  and  tonic. 

At  this  time  an  allowance  of  port,  brief  rest  and 
change  of  air  are  old  remedies  ;  and  even  if  the  patient 
had  not  already  been  in  declining  health  when  the  attack 
occurred,  he  would  certainly  be  enfeebled  by  it,  and 
will  need  such  restoratives  for  a  week  or  ten  days  before 
resuming  work  and  risking  fresh  exposure  to  the  cir- 
cumstances inducing  infection,  if  those  cannot  be  avoided. 

It  is  not  pretended  that  the  distinction  between  these 
three  forms  of  sore  throat  is  obvious  or  at  all  easily 
made.  Rheumatic  sore  throat,  perhaps,  is  marked  by  the 
more  abrupt  accession  of  fever,  and  the  local  appearances 
are  cleaner  and  more  definitely  hypersemic.  Moreover, 
recurrence  of  the  affection  in  the  same  individual  under 
different  circumstances,  the  persistent  enlargement  of 
the  tonsils  as  a  legacy  of  previous  attacks,  and  the  early 
response  to  salicylates  aid  in  the  diagnosis. 

Even  greater  is  the  difficulty  of  discrimination 
between  the  septic  and  diphtheritic  cases.  It  might  even 
be  said  that  both  are  septic  and  that  the  latter  differs 
only  in  having  the  specific  organism  of  diphtheria  super- 
imposed upon  the  common  infection. 

In  the  absence  of  bacteriological  investigation,  the 
distinction  will  depend  on  the  tendency  of  diphtheria 
to  extend  early  to  adjacent  areas,  and  to  give  rise  to 
distinctive  symptoms,  though,  as  has  been  previously 
stated,  these  may  develop  too  late  to  aid  the  initial 
diagnosis. 

With  the  exception,  however,  of  the  use  of  anti- 
diphtheritic  serum,  the  remedies  that  have  been  suggested 
are  alike  beneficial  in  the  simple  septic  throat  and  that 
affected  by  diphtheria,  being  as  strongly  antiseptic  as 
is  compatible  with  safety. 

Folliculap  Pharyngitis. — A  sensation  of  prick- 
ing-soreness or  stiffness  in  the  throat,  with  cough  and, 


Catarrhal  Sore  Throat  97 

sometimes,  alteration  in  the  quality  of  the  voice,  usually 
indicate  this  complaint,  which  commonly  follows  the 
inhalation  of  some  irritant.  By  far  the  most  common 
cause  is  tobacco-smoking,  but  it  may  result  from  dust, 
or  the  fumes  in  a  chemical  laboratory.  The  malady 
afiEects  the  back  of  the  pharynx  and  is  characterised  by 
a  dry  glazed  condition  of  the  mucous  membrane  with 
raised  red  spots  representing  the  inflamed  lymph  follicles. 
With  avoidance  of  the  cause,  the  condition  usually 
subsides,  but  it  is  readily  excited  again. 

Local  remedies  are  not  easy  to  apply,  as  the  region  is 
scarcely  to  be  touched  without  exciting  swallowing 
or  retching.  Some  relief  may  be  obtained  by  sucking 
marsh  mallow,  black  currant  or  glycerine  jujubes,  or 
the  compound  benzoic  acid  lozenges  of  the  London 
Throat  Hospital  (Ac.  Benzoic!  gr.  |  in  red-currant  basis). 

In  this  and  other  forms  of  vascular  injection,  a  spray 
of  adrenahn  solution  (1-1000)  has  an  immediate  re- 
medial effect,  but  requires  to  be  repeated  in  two  or  three 
hours. 

Catapphal  Sore  Throat. — It  occasionally 
happens,  and  in  some  individuals  with  greater  frequency 
than  in  others,  that  an  ordinary  catarrh  commences  in  the 
neighbourhood  of  the  soft  palate,  constituting  for  some 
hours  a  sore  throat.  The  infection  soon  spreads  to  the 
nares  or  trachea,  or  both,  so  that  the  nature  of  the  attack 
is  soon  evident,  and  it  is  only  worth  while  referring  to 
it  here  to  suggest  that  full  development  may  be  some- 
times prevented  by  applying  to  the  palate  and  fauces 
the  remedies  suggested  farther  on  as  curative  when  the 
complaint  commences  in  the  nostrils. 

Catapph. — What  is  commonly  called  a  "  cold  "  in 
the  head,  chest,  or  throat  is  really  an  infective  inflamma- 
tion of  the  mucous  membrane.  Though  it  is  fully 
accepted  that  such  an  affection  is  transferable  from 
one  person  to  another — and  instances  are  in  every  one's 

7 


98  Catarrh 

experience  where  the  malady,  once  introduced,  has 
passed  from  one  member  to  another  throughout  a  house- 
hold— people  still  cling  to  the  notion  that  catarrh  arises 
de  novo  from  exposure  to  cold. 

Ill  consequences  result,  no  doubt,  from  sudden  or 
prolonged  exposure  to  cold,  but  catarrh  is  not  one  of 
them,  as  witness  the  absence  of  such  troubles  in  the 
many  arctic  expeditions  and  their  rarity  in  open-air 
life  under  any  circumstances,  to  say  nothing  of  the  fact 
that  some  of  the  worst  attacks  of  the  kind  occur  in  the 
hot  weather.  This  much  may  be  conceded,  that  pro- 
longed exposure  to  a  low  temperature  when  inactive, 
or  sudden  chill  when  overheated,  lessen  resistance  and 
predispose  to  microbic  invasion.  Furthermore,  cold, 
and  inclement  weather  compel  many  to  lead  an  indoor 
life,  which  is  the  reverse  of  invigorating,  and  commonly 
tend  to  a  limitation  of  ventilation  ;  but  the  most  usual 
source  of  infection  is  a  crowded  gathering  under  cover, 
which  supplies  an  overheated,  vitiated  atmosphere,  and 
is  seldom  wanting  in  the  elements  of  infection. 

The  onset  of  nasal  catarrh  is  usually  marked  by 
irritation  within  one  nostril,  which  may  be  expressed  by 
slight  soreness  or  tickling,  sneezing  or  thin  watery  dis- 
charge, accompanied  by  slight  fever  manifested  by 
"  chilliness."  It  is  in  this  stage  that  the  attack  m.a>j  be 
aborted  by  appropriate  treatment,  though  it  will  not  be 
denied  that  subsidence  may  occur  spontaneously. 

The  remedies  that  have  been  advocated  are  all  either 
antiseptics  or  astringents. 

The  most  convenient  formula  is  a  liquid  which  may 
be  sprinkled  on  the  handkerchief  and  inhaled : 

^.  Terebene  "| 

01.  Eucalypti  I      .. 

Camphor  j 

Menthol  J 

Eau  de  Cologne  may  be  added  if  desired,  but  the 


Nasal  Douche  99 

combination  as  it  stands  makes  a  very  powerful  aromatic 
germicide.  If  kept  in  readiness  and  freely  inhaled  as 
soon  as  the  early  irritation  is  experienced,  subsequent 
development  of  catarrh  is  often  avoided. 

Another  convenient  remedy  is  menthol  snuff,  but  it 
is  neither  so  cleanly  nor  efficient  as  the  fluid.  Those 
who  have  been  initiated  into  the  use  of  the  nasal  douche 
may  apply  a  weak  antiseptic  solution,  but  a  special 
contrivance  is  necessary  and  the  knack  has  to  be  acquired. 
The  douche  consists  of  a  glass  vessel  with  a  capacity  of 
an  ounce  or  more  having  an  opening  at  the  top  which 
can  be  closed  by  the  finger,  and  a  nozzle  below  to  fit  the 
nostril.  Its  use  is  perfectly  simple  but  requires  a  little 
confidence. 

Having  filled  the  douche- while  the  lower  opening  is 
closed  by  the  thumb,  a  finger  is  placed  over  the  upper 
opening,  thus  retaining  the  contents  by  atmospheric 
pressure. 

The  nozzle  is  then  inserted  into  one  nostril,  the  head 
being  thrown  back  and  slightly  inclined  to  the  opposite  side 
over  a  basin.  On  releasing  the  finger  capping  the  upper 
orifice,  the  fluid  is  delivered  steadily,  and  provided  the 
user  breathes  boldly  through  the  mouth,  it  will  run  round 
the  back  of  the  soft  palate  and  out  at  the  other  nostril. 
Should,  however,  the  breath  be  held,  or  an  inspiration 
be  taken  through  the  nose,  the  fluid  will  pass  into  the 
throat  or  even  into  the  larynx,  and  a  bad  fit  of  choking 
result. 

The  coUunaria  mentioned  may  be  used  in  a  simpler 
manner  by  sniffing  them  into  the  nostrils  from  the  palm 
of  the  hand,  but  this  is  not  so  satisfactory. 

Whatever  ingredients  be  used,  the  fluid  should 
approximate  to  the  "  normal  saline  solution,"  otherwise 
uncomfortable  smarting  will  occur.  As  the  mucous 
membrane  is  highly  sensitive,  any  reagents  employed 
must  be  well  diluted.     In  addition  the  fluid  should  be 


loo  Collunaria 

slightly   alkaline   and  of  the  same  temperature  as  the 
blood. 

Glycothymoline,  though  expensive,  is  satisfactory, 
otherwise  a  solution  of  Bicarbonate  of  Soda  or  Borax, 
4  grains  of  either  to  the  ounce  of  water,  may  be  employed 
as  a  basis,  to  which  may  be  added  vi  xx  of  Hazeline  or 
a  minute  quantity  {-^^  grain)  of  Menthol.  Alum  gr.  v 
ad  5  3  ;  Liq.  Potass.  Permanganate  tii  vj  ad  5  j ;  Sulphate 
of  Quinine  or  Zinc  gr.  |  ad  ^  J  5  ^^id. 

DobeH's  Solution 

'^.  Glycerini  Acidi  Carbolic! .        .  .  .  m  x 

Sodii  Biboratis  ...  ,  .  gr  vj 

Sodii  Bicarbonatis     .        .        .  .  .  gr  vj 

Aquam  ad          .                 •        •  •  ■  5j 

are  also  employed. 

When  a  catarrh  has  passed  the  initial  stage  of  infection 
and  irritation,  it  is  beyond  the  influence  of  nasal  douches, 
sprays,  or  inhalations,  and  may  be  expected  to  run  its 
course  with  but  little  modification  by  remedies.  The 
entire  thickness  of  the  mucous  membrane  is  then  involved ; 
active  congestion,  swelling,  and  soon  increased  secretion, 
passing  through  the  stages  of  mucus  and  mucopus, 
marking  its  progress.  The  air  passages  are  more  or  less 
obstructed  and  there  is  either  sneezing  or  cough,  and 
some  degree  of  fever.  Recourse  must  then  be  had  to 
general  principles,  in  order  to  diminish  the  severity  and 
shorten  the  course  of  the  affection  while  relieving  the 
discomfort  of  the  more  prominent  symptoms.  A  hot 
bath  and  some  hot  wine  negus  or  spirit  and  water,  with 
perhaps  the  addition  of  half  a  drachm  of  sweet  spirits  of 
nitre,  are  homely  remedies.  The  patient  should  retire 
early  and  have  an  extra  blanket  or  two  on  the  bed,  which 
should  be  warmed  so  as  not  to  check  the  action  of  the 
skin,  started  by  the  hot  bath. 

A  saline  purge  in  the  morning  is  useful  both  as  re- 


Treatment  '    loi 

lieving  the  fever  generally  and  diminishing  the  degree  of 
swelling  or  secretion  in  the  mucous  membrane. 

These  measures  are  not  incompatible  with  the  usual 
routine  of  life,  for  it  is  not  every  one  who  will  seclude 
himself  on  account  of  an  attack  of  catarrh. 

Nevertheless,  for  the  sake  of  avoiding  conveyance  of 
infection  to  others,  as  well  as  to  ensure  speedy  recovery 
and  the  avoidance  of  more  serious  developments,  con- 
finement to  one  room  or  even  to  bed  is  strongly  recom- 
mended. To  "  feed  a  cold  and  starve  a  fever  "  is  an 
old  adage,  but  perhaps  it  would  be  more  practical  to 
suggest  that  solid  food  for  the  one  and  liquid  for  the 
other  should  be  the  rule. 

Reducing  the  amount  of  liquid  taken  to  the  smallest 
possible  minimum  has  a  decided  effect  in  reducing  the 
nasal  discharge,  which  constitutes  the  leading  feature 
in  a  "  cold  in  the  head." 

The  only  medicine  likely  to  be  of  service  in  the  course 
of  the  complaint  is  quinine,  which  may  be  taken  as  the 
ammoniated  tincture  in  drachm  doses  every  four  hours 
before  meals  for  three  or  four  days,  or  the  following 
mixture  may  be  substituted  : 

^.  Tinct.  Nucis  Vom m  v 

Tinct.  Cinchon,  Co 5  S3 

Sp.  Am.  Arom.  .                 ,        ,        .  tii  xx 

Aq.  Chlorof  Ormi        .        .        ,        .  ad  §  j 

Every  four  hours. 

At  the  outset  it  is  not  always  evident  whether  the 
chief  manifestations  will  be  in  the  head  or  in  the  chest. 
If  the  initial  change  is  in  the  throat,  it  commonly  extends 
to  both,  and  a  cold  in  the  head  not  infrequently  spreads 
later  to  the  trachea  and  larger  tubes,  especially  if  no 
precautions  have  been  taken.  Provided  there  are  no 
constitutional  conditions  or  idiosyncrasy  to  prohibit  it,  a 
lO-grain  dose  of  Dover's  powder  at  night  is  one  of  the  best 
remedies  for  a  feverish  cold  in  an  adult.     Salol  in  lO-graiu 


102  Tracheitis 

doses  in  cachet  twice  or  three  times  a  day  will  mitigate  the 
feverish  and  catarrhal  symptoms  in  the  early  stage. 

For  laryngeal  catarrh,  characterised  by  loss  of 
voice  and  painful  brassy  cough,  chloride  of  ammonium 
in  10  or  15-grain  doses  every  four  hours  is  a  suitable 
remedy.  It  can  be  given  in  solution  with  compound 
tincture  of  camphor  and  sjTup  of  tolu. 

Adrenalin  spray  or  local  application  of  Gaultherium 
Oil,  5  j  in  a  hot  fomentation  or  as  an  ointment  5  ij  to 
Lanoline  3  j  over  the  front  of  the  neck  at  night  will  do 
much  to  restore  the  voice,  often  within  twelve  hours. 

When  there  is  much  irritation,  with  cough  and  op- 
pression of  breathing,  the  inhalation  of  vapour  from  5  j 
of  Tincture  of  Benzoin  and  a  pint  of  boiling  water,  gives 
much  relief. 

The  readiest  method  is  to  place  about  a  pint  of  boiling 
water  with  the  tincture  in  a  jug,  and  then  wind  a  folded 
towel  round  it,  so  that  this  projects  three  or  four  inches 
above  the  top  ;  serving  the  double  purpose  of  retaining 
the  heat,  and  providing  a  close  soft  face-piece. 

Traeheitis. — Catarrh  of  the  mucous  membrane  of 
the  windpipe,  which  constitutes  a  "  cold  in  the  chest," 
may  either  occur  primarily  from  exposure  to  infection, 
or  may  be  due  to  extension  from  the  nose  or  larynx. 
Neglect  and  exposure  to  cold  and  moist,  or  extremely 
dry,  air,  especially  when  coming  out  of  a  warm  room, 
may  lead  to  further  involvement  of  the  bronchi  and 
serious  illness.  Whatever  risks  are  taken  in  connection 
with  nasal  catarrh,  it  is  certainly  perilous  to  keep  about 
and  go  out  of  doors  with  either  laryngitis  or  tracheitis. 

The  symptoms  are  very  definite — a  scalding  or  burning 
sensation  behind  the  sternum,  rough  breathing,  and  a 
hoarse  frequent  and  painful  cough  with  definite  rise  of 
temperature.  There  is  at  first  complete  dryness,  then 
a  thin  irritating  and  scanty  expectoration  followed  by 
more  copious    mucus  and  muco-pus   as  the  acute  stage 


Treatment  103 

subsides.  The  voice  is  always  hoarse  in  some  degree, 
and  attempts  at  speaking  provoke  cough.  The  ex- 
pectoration may  be  tinged  or  streaked  with  blood. 

Household  remedies  are  the  application  of  a  mustard 
poultice  to  the  upper  part  of  the  chest  for  ten  minutes 
and  sipping  simple  linctus  or  a  mixture  of  equal  parts  of 
lemon  juice  and  either  honey  or  glycerine,  or  equal  parts 
of  Tinct.  Camph.  Co.,  Oxymel  scillse,  and  lemon  juice. 
A  milder,  but  still  effectual,  modification  of  the  poultice 
may  be  made  by  rubbing  about  a  teaspoonful  of  dry 
mustard  flour  into  a  piece  of  wadding,  placing  this  on 
the  chest  and  covering  with  a  sufficiently  large  piece  of  wet 
oil-silk  or  protective  to  extend  an  inch  beyond  it  all 
round.  When  this  is  pressed  down,  the  free  edge  adheres 
to  the  skin  and  the  warmth  of  the  body  liberates  the 
essential  oil,  producing  a  mild  irritation  which  can  be 
borne,  without  fear  of  blistering,  all  night.  The  counter- 
irritant  effect  is  thus  prolonged  and  the  chance  of 
marking  a  delicate  skin  diminished.  The  general  treat- 
ment should  be  the  same  as  that  employed  for  nasal 
catarrh,  but  some  demulcent  is  acceptable  such  as 
rum  and  warm  milk,  thin  gruel  or  milk  arrowroot 
with  brandy  or  whisky  on  going  to  bed ;  the  same 
principles  in  regard  to  diaphoresis  and  purgation  being 
observed. 

If  the  complaint  does  not  yield  to  these  measures, 
and  especially  if  there  is  a  tendency  for  inflammation 
to  extend  into  the  bronchi  with  increase  in  fever  and 
dyspnoea,  the  following  prescription,  the  type  of  the 
sedative  expectorant,  should  be  ordered  : 


Vin.  Antimon 

HI  X 

Vin.  Ipecac 

HI  X 

Sp.  ^th.  Nitros, 

3ss 

Liq,  Am.  Acet 

5ij 

Syrup.  Limon 

.        3j 

Mist.  Amygdal  .... 

.     acT§i 

Jlvery  four  hours. 

I04  Treatment 

And    later,    when    secretion   is   established    and    fever 
declines  : 


Ammon.  Carb.    . 

•        •        • 

.      gr.  V 

Tinct,  Camph.  Co. 

•        •        • 

.     ni  XX 

Syr.  Scillae . 

oss 

Syr.  Tolu    . 

. 

53 

Inf.  Senegse 

. 

.    adgj 

Every 

four  hours. 

this  being  the  type  of  the  stimulant  expectorant. 

These  remedies  are  suitable  for  otherwise  healthy 
adults,  but  it  is  as  well  to  state  that  ipecacuanha  and 
antimony  are  too  depressing  to  be  used  when  the  heart 
is  not  sound,  either  in  the  presence  of  valvular  disease 
or  the  more  obscure  condition  of  myocardial  degeneration 
with  weak  and  irregular  pulse. 

Squill  and  carbonate  of  ammonia  are  both  irritants, 
and  they  must  be  eliminated  should  nausea  or  vomiting 
ensue.  To  infants  or  children  opium,  even  as  the 
camphorated  tincture,  should  not  be  given,  owing  to 
their  peculiar  susceptibility. 

Though  carbonate  of  ammonium  acts  as  an  irritant 
in  concentrated  solution,  it  may  be  given  in  much  larger 
doses  properly  diluted.  Dissolved  in  a  tumblerful  of 
milk,  10,  15  and  even  30  grains  can  thus  be  administered 
without  discomfort,  acting  as  a  reliable  stimulant, 
especially  in  those  cases  where  an  expectorant  is  required. 

In  all  cases  of  tracheitis  and  bronchitis,  one  of  the 
most  important  matters  to  observe  is  the  maintenance 
of  a  uniformly  moist  and  warm  atmosphere.  This  assists 
greatly  in  allaying  irritation  and  spasm,  and  is  especially 
necessary  during  a  dry,  cold  north-east  or  east  wind. 
The  object  is  best  attained  by  a  steam  jet  which  not 
only  moistens  the  air,  but  raises  the  temperature  rapidly 
and  is  an  efficient  deodoriser. 

For  children  the  following  mixture  is  generally 
useful,  half  the  quantity  being  given  to  infants  ; 


Cough  105 

^.  Vin,  Ipecac 3  ss 

Tinct.  ScillEe    .        .        .        •        .         3  ss 
Sp.  Am.  Arom.  .        .        .        .         3  ss 

Glycerini 3j 

Aq.  destill.        .  .        .        .  adgjss 

Dose :  3  j-ij  every  four  hours. 

Cough. — Dwellers  in  towns,  particularly  during  the 
winter,  are  prone  to  habitual  cough  with  slight  greyish 
expectoration,  which  is  particularly  noticeable  in  the 
mornings.  This  is  only  the  natural  reaction  of  the 
bronchial  tubes  to  the  irritation  of  inhaled  soot,  usual 
under  such  circumstances,  and  does  not  call  for  any 
treatment,  nor  need  it  give  rise  to  any  anxiety,  but 
must  be  looked  upon  as  one  of  the  penalties  of  modern 
civilisation. 

Apart  from  pulmonary  disease,  cough  may  be  a 
source  of  annoyance  both  to  the  individual  affected  and 
perhaps  still  more  to  his  neighbours.  Absence  of  ex- 
pectoration and  the  accompanying  rattle  in  the  throat 
usually  characterise  cough  dependent  on  causes  remote 
from  the  respiratory  system,  which,  being  dependent  on 
less  urgent  stimulation,  is  usually  absent  during  sleep. 

Dryness  or  inflammation  of  the  fauces  or  pharynx 
commonly  causes  sudden  and  impulsive  cough,  with 
watering  of  the  eyes  and  often  retching.  Some  persons 
even  suffer  in  this  way  on  cleaning  the  teeth.  Gargles  or 
demulcent  pastilles  are  the  appropriate  remedies,  and 
as  the  symptom  prevails  most  when  getting  up  or  going 
to  bed,  the  use  of  these  agents  may  be  limited  to  those 
occasions. 

A  more  frequently  repeated  dry  cough  is  sometimes 
associated,  especially  in  children  and  young  adults,  with 
the  irritation  associated  with  nasal  obstruction,  foreign 
matter  in  the  external  auditory  meatus,  or  bad  teeth, 
and  these  causes  of  disturbance  should  be  looked  for 
and  remedied,  rather  than  having  recourse  to  drugs. 

Another   group    of   causes   is   subdiaphragmatic,    ii> 


io6  Treatment 

eluding  morbid  conditions  of  the  liver  and  kidneys,  but 
especially  disorders  of  the  stomach  and  colon.  The  loud 
barking  cough  of  boys  and  girls — more  often  the  latter — 
from  eight  to  twelve  or  fourteen  years  of  age — which  from 
its  long  persistence  sometimes  leads  to  fears  of  grave 
thoracic  disorder — will  generally  be  found  to  yield  to 
rhubarb  and  soda  and  proper  supervision  of  diet.  It 
is  generally  associated  with  a  furred  tongue,  capricious 
appetite  for  plain  food,  and  recurrence  of  "  bilious 
attacks";  the  tendency  at  this  age  to  hurry  over  meals 
without  proper  mastication,  and  to  supplement  them 
with  more  attractive  and  less  wholesome  articles  of  diet, 
being  largely  responsible,  though  defective  teeth  may 
have  a  share  in  the  disorder. 

The  condition  is  indeed  one  of  chronic  catarrh,  and 
oftentimes  dilatation,  of  the  stomach,  which  yields  to  a 
proper  regimen  and  occasional  dose  of  Gregory's  powder, 
the  Pulvis  Rhei  Co.  of  the  Pharmacopoeia.  In  young 
women  and  girls  from  fourteen  years  upwards,  such 
cough  may  be  due  to  the  same  condition,  but  perhaps 
more  often  to  constipation,  and  is  more  conveniently 
treated  with  the  Compound  Rhubarb  pill  or  Cascara 
Sagrada,  which  may  be  administered  in  capsules  repre- 
senting half  a  drachm  of  the  liquid  extract,  or  more 
agreeably  as  the  Aromatic  Syrup  of  Cascara  5  ss-ij . 
These  are  by  far  the  commonest  forms  of  dry  cough, 
and  the  most  assertive,  being  particularly  in  evidence 
in  schooldays. 

There  is,  however,  one  variety  even  more  noisy, 
frequent,  and  demonstrative,  and  that  is  the  hysterical 
cough  of  young  women.  I  was  once  consulted  in  such 
a  case,  the  paroxysms  being  so  violent  that  the  buttons 
flew  off  the  patient's  dress  in  all  directions,  and  had  it 
not  been  for  the  persistence  and  recurrence  of  the  attacks 
and  the  general  characteristics  of  the  individual,  the 
diagnosis  would  have  been   whooping   cough.      In   such 


Pleurodynia  107 

cases  bromide  and  valerian  combined  with  some  dis- 
ciplinary supervision  are  required. 

One  word  of  warning  may  perhaps  be  necessary  before 
leaving  the  subject  of  dry  and  paroxysmal  cough,  and 
that  is  to  insist  on  a  careful  examination  of  the  chest, 
so  as  to  exclude  any  local  physical  conditions  before 
attributing  the  cough  to  remoter  causes.  In  rare  cases, 
mediastinal  growth  or  aneurysm  may  be  present,  or 
the  irritation  may  proceed  from  adherent  pleura  or 
enlarged  bronchial  glands,  or  be  due  to  whooping  cough 
itself.  Indeed,  the  frequency  with  which  the  latter  com- 
plaint is  said  to  follow  measles  may  be  accounted  for  by 
the  presence  of  adenitis  of  the  bronchial  glands. 

Dry,  irritant  cough,  due  to  remote  causes  which 
cannot  be  directly  remedied,  is  best  checked  by  some 
preparation  of  opium  ;    morphia,  codeia  or  heroin. 

Pleurodynia. — Pain  in  the  side  is  commonly  re- 
garded as  coming  into  the  category  of  the  respiratory 
system,  though  with  the  exception  of  that  due  to  pleurisy 
this  is  not  exactly  correct.  The  pain,  usually  referred  to 
the  infra-axillary  region,  may  have  one  of  three  sources 
of  origin,  which  may  be  discriminated  by  the  effect  of 
pressure  with  the  hand. 

If  there  is  hypersesthesia,  excited  by  the  lightest 
stroking  or  pinching  the  skin,  the  complaint  is  probably 
Neuralgia,  either  associated  with  anaemia  or  with  herpes, 
preceding  or  following  the  appearance  of  the  characteristic 
rash.  The  anaemic  form  may  be  relieved  by  the  admin- 
istration of  Quinine  and  Iron  (5-10  grains  of  the  combined 
citrates),  the  Syrupus  Ferri  Phosphatis  cum  Quinina 
et  Strychnina  (s^-j),  or  a  mixture  of  Iron  and  Arsenic 
as  follows  : 

"^i.  Tinct.  Ferri  Perchlor iti  x 

Liq.  Arsenic.  Hydrochlor.    ,        .        .     tii  v 

Glycerini 5ss 

Aq.  Chloroformi   .         .        .        .         .  ad  §  j 
Tbree  times  a  day  after  food, 


io8  Myalgia 

Locally  some  relief  may  be  obtained  by  the  locaJ 
application  of  Anodyne  Colloid  covered  with  moist 
spongiopiline,  Linimentum  Belladonnse  or  Linimentum 
Chloroformi  5  j  with  Menthol  5  3,  the  Belladonna  plaister, 
or  the  recently  introduced  compound  of  saUcylates  and 
menthol  known  as  Kasemol. 

For  herpetic  pain  the  same  local  remedies  may  be 
applied,  but  constitutional  ones  are  less  efficacious.  If 
antip3n:'ine  fails,  one  must  have  recourse  to  morphine 
when  the  suffering  is  very  severe.  The  following 
prescription  may  benefit : 


^.  Sodje  Salicylatis 
Sodse  Bromidi  . 
Antipyrin. 
Aq.  CamphorEe 


|-  aa  gr.  x 

5j 


Three  times  a  day. 


When  there  is  not  superficial  hypersesthesia,  but  deep 
tenderness  of  an  aching  character  is  elicited  by  pressure, 
the  condition  is  most  likely  Myalgia.  The  best  remedies 
then  are  sahcylates  both  internally  and  externally. 

Aceto-salicylic  acid  (aspirin)  may  be  given  in  10-grain 
doses  in  cachet  or  tabloid,  and  oil  of  wintergreen  may 
be  applied  locally,  either  3  3  in  a  hot  fomentation  or 
5  ij  to  5  j  of  wool  fat.  This  may  either  be  gently  rubbed 
into  the  skin  or  may  be  applied  on  a  strip  of  linen  or 
lint.  If  the  patient  is  in  bed,  a  hot  rubber  water  bottle 
placed  against  the  painful  region  affords  rapid  relief. 

The  third  variety  of  pain  is  a  combination  of  soreness 
or  aching,  -^dth  acute  stabbing  paroxysms  on  coughing 
or  taking  a  deep  breath.  There  may  be  a  slight  rise  of 
temperature  and  the  patient  usually  holds  the  side  with 
the  hand  when  coughing  or  moving,  or  involuncarily  sus- 
pends respiratory  movement  in  some  degree  on  the 
affected  side.  Flicking  or  percussing  excites  tenderness, 
but  gentle  and  firm  comprehensive  pressure  with  the 
whole    hand,    sufficient    to    restrain    the    movement    of 


Pleurisy  109 

the  ribs,  gives  ease.  This  is  Pleurisy.  In  many  cases 
friction  may  be  heard  with  the  stethoscope,  but  not 
in  all. 

The  most  efficient  treatment  consists  in  strapping  the 
side  (Dr.  Fred.  Roberts).  It  is  an  advantage  to  soften 
the  surface  of  the  plaister  with  turpentine  instead  of 
heat,  as  this  acts  as  a  counter-irritant  besides  ensuring 
a  good  grip. 

Two  strips,  two  inches  wide  and  long  enough  to  cross 
the  middle  line  in  front  and  behind,  should  be  applied 
diagonally  in  an  X  shape,  crossing  at  the  seat  of  pain. 
Each  strip,  held  firmly  over  the  spine,  should  be  carried 
round  the  chest  and  fixed  at  the  end  of  expiration.  After 
a  day  or  two  the  strapping  may  need  re-adjusting,  as 
it  is  apt  to  loosen  with  the  movements  of  the  chest. 

Temporarily  holding  the  affected  side  of  the  thorax 
with  the  hand  is  of  value  in  estimating  the  probable 
effect  of  fixation  on  the  pain  and  also  on  respiration,  for 
in  those  cases  where  this  is  already  much  embarrassed 
by  existing  pulmonary  disease,  fixation  is  not  tolerated. 
Recourse  must  then  be  had  to  leeches  or  counter-irritation, 
such  as  painting  with  a  preparation  of  iodine  or  applying 
mustard  or  emplastrum  calefaciens. 

Dry  pleurisy  is  an  occasional  accompaniment  of  bron- 
chitis and  emphysema,  or  may  occur  from  exposure  to 
cold  or  trauma,  but  is  more  often  associated  with 
constitutional  disease  such  as  gout,  rheumatism,  renal 
disease,  and  pulmonary  tubercle,  which  should  be 
carefully  sought  for. 

Stiteh  in  the  Side. — This  common  phenomenon, 
familiar  to  every  one,  generally  accompanies  unusual 
exertion,  particularly  after  a  meal,  or  in  those  unac- 
customed to  violent  exercise.  The  pain  is  nearly  always 
referred  to  the  hypochondrium  on  either  side,  though 
it  may  ascend  as  high  as  the  nipple,  and  has  all  the 
characters  of  the  pleuritic  stab. 


no  Stitch  in  the  Side 

It  is  due  to  desiccation  of  the  serous  membrane 
not  necessarily  of  the  pleura,  the  peritoneum  being 
sometimes  involved,  but  always  in  the  region  of  the 
diaphragm,  and  appears  often  to  be  associated  with 
turgescence  of  the  liver  or  spleen  during  digestion. 
This  desiccating  effect  of  movement  on  the  serous  mem- 
brane is  fully  recognised  and  has  been  made  use  of  in 
hastening  the  absorption  of  chronic  pleural  effusion. 

The  pain  is  so  sharp  and  so  closely  bound  up  with 
respiratory  movement  that  it  effects  its  own  cure,  by 
bringing  the  patient  to  a  standstill,  and  causing  him 
to  support  the  affected  area  with  his  hand.  After 
subsiding,  it  is  very  apt  to  recur  with  renewed  exertion, 
but  ceases  to  give  trouble  as  the  subject  becomes  inured 
to  exercise,  especially  if  he  avoids  taking  it  immediatelj^ 
after  a  meal. 

A  stitch  in  the  side  is  so  transient,  and  the  circum- 
stances in  which  it  occurs  do  not  afford  opportunity  for 
auscultation,  or  a  friction  rub  might  be  heard. 

In  the  course  of  disease  affecting  the  liver  or  spleen, 
such  as  infarcts,  new  growths,  and  passive  congestion  or 
inflammatory  hypersemia,  a  similar  but  more  persistent 
pain  occurs,  increased  by  respiratory  movement  or 
cough  and  accompanied  by  audible  friction.  This  is 
amenable  to  the  same  remedies  as  pleurisy. 


CHAPTER    IV 
NERVOUS    SYSTEM 

Insomnia. — Except  in  the  treatment  of  definite  and 
acute  affections  and  on  special  occasions  the  use  of  drugs 
should  be  entered  upon  very  guardedly  in  dealing  with 
insomnia.  In  otherwise  healthy  people  in  whom  a  bad 
night  or  two  may  be  looked  upon  in  the  Hght  of  a  minor 
disorder,  the  correction  of  some  physiological  error  may 
be  all  that  is  needed  to  guard  against  a  recurrence.  Over- 
fatigue, especially  when  associated  with  a  late  and  un- 
digested meal,  is  a  common  cause  of  failure  of  much- 
wanted  sleep,  even  in  those  who  are  young  and  active. 
On  such  occasions  a  warm  bath  following  a  light  and 
digestible  meal  with  more  than  the  usual  quantity  of 
fluid,  preferably  hot,  makes  the  best  preparation  for 
retiring.  Otherwise  the  inclination  to  sleep  should  be 
combated  till  sufficient  time  (three  hours)  has  been  allowed 
for  the  primary  stages  of  digestion  and  the  elimination 
of  some  of  the  waste  products  of  the  muscles.  On  the 
other  hand,  an  empty  stomach  is  a  watchful  companion, 
so  that  in  seeking  rest  five  hours  or  more  after  the  last 
meal,  sleep  is  best  secured  by  some  light  nourishment 
such  as  soup,  milk,  gruel,  arrowroot,  chocolate,  or  warm 
milk  alone.  Sometimes  on  waking  during  the  night  from 
a  similar  cause  a  biscuit  or  piece  of  chocolate  is  sufficient 
to  restore  repose.  A  loaded  colon,  a  stomach  dilated 
with  gas,  often  from  drinking  aerated  waters  late  at 
night,  or  intestinal  flatulence  will  prevent  or  disturb 
sleep. 


1 1 1  Insomnia 

Undue  excitement  of  the  brain  up  to  the  time  of  going 
to  bed,  excess  of  tobacco  or  taking  tea  or  coffee  late  in 
the  evening  may  have  the  same  effect,  and  it  is  sometimes 
overlooked  in  the  treatment  of  invalids  that  such  drugs 
as  strychnine,  caffeine,  and  theobromine  given  for  other 
purposes  may  exert  a  similar  influence.  Conditions  less 
obvious  to  the  patient  are  variations  from  the  normal 
in  the  circulation.  Perhaps  the  most  persistent  cause  of 
sleeplessness  is  high  arterial  tension,  which  may  be  asso- 
ciated with  chronic  renal  disease  and  arterio-sclerosis,  or 
may  occur  occasionally  from  some  disturbance  in  the 
digestive  tract.  Port  wine  exercises  such  an  influence 
in  some  individuals,  especially  if  taken  in  the  evening. 
This  is  best  remedied  by  a  warm  bath  before  retiring. 
AlUed  to  this  state  is  the  presence  of  rigid  arteries  in  the 
brain,  chiefly  in  old  age,  which  interferes  with  the  adjust- 
ment of  the  cerebral  circulation.  In  the  opposite  direc- 
tion, the  enfeebled  vaso-constrictor  action  in  anaemia 
and  debility,  convalescence  after  acute  disease,  especially 
typhoid  fever  and  influenza,  and  in  Grave's  disease,  allows 
of  dilatation  of  the  cerebral  arteries  automatically  on 
lying  down,  so  that  such  subjects  often  fall  asleep  more 
easily  when  sitting  up  if  sufficiently  supported,  as  in  a 
"  grandfather's  chair."  It  need  hardly  be  mentioned 
that  undue  cold  or  heat,  noise  and  light,  or  the  attempt 
to  maintain  a  position  incompatible  with  complete  mus- 
cular relaxation,  are  all  opposed  to  satisfactory  rest. 

In  dealing  with  insomnia,  as  with  other  prominent 
symptoms  of  disturbed  function,  it  is  therefore  obvious 
that  very  nice  discrimination  is  needed  both  to  attain 
a  satisfactory  result  and  to  avoid  needless  injury.  It  is 
just  as  unreasonable  to  apply  soporiflcs  without  judgment 
in  the  relief  of  sleeplessness  as  it  is  to  employ  analgesics 
unthinkingly  in  subduing  pain.  Each  in  its  way  is  an 
indication  of  a  pathological  condition  which  should  be 
carefully    investigated    and    suitably    dealt    with,    the 


Treatment  113 

objectionable  symptom  in  each  case  disappearing  with 
the  correction  of  the  underlying  cause.  As  an  expedient 
in  either  case,  some  remedies  may  be  applied  to  the 
direct  relief  of  the  symptoms  while  the  cause  is  removed 
or  when  this  cannot  be  discovered  or  corrected. 

In  its  serious  and  persistent  form,  such  as  precedes 
or  accompanies  acute  attacks  of  insanity  or  is  associated 
with  serious  organic  disease,  no  symptom  is  more  dis- 
tressing and  damaging,  or  more  difficult  to  control,  than 
the  inability  to  sleep.  Such  powerful  remedies  as  are 
called  into  requisition  on  these  occasions  can  only  bi 
administered  with  the  utmost  precaution  and  watched 
with  the  most  anxious  care ;  these  are  morphine  and 
hyoscyamine,  chloral  and  even  chloroform. 

In  the  restlessness  of  pneumonia,  pleurisy  or  pericarditis 
especially  when  pain  or  dry  cough  is  present,  in  the  early 
stages,  small  doses  of  morphine  (^  or  J  gr.)  give  great  relief, 
and  delirium  may  entirely  disappear  under  its  influence, 
or  after  the  sleep  it  induces,  but  it  should  of  course  not 
be  administered  when  cyanosis  is  present,  as  it  would 
dangerously  deepen  the  stupor  of  asphyxia.  In  cardiac 
disease,  too,  where  restlessness  and  sleeplessness  are 
prominent  features  leading  on  to  delirium,  the  timely 
exhibition  of  this  drug  affords  much  benefit.  It  is  best 
administered  hypodermically  in  combination  with  strych- 
nine and  atropine,  a  good  formula  being  Morphine  gr.  J, 
Atropine  gr.  ^Ijj,  and  Strychnine  gr.  -^^  in  6  minims  of 
water  ;  half  this  dosage,  viz.  3  minims,  usually  suffices, 
especially  after  the  first  administration.  In  all  instances, 
in  which  there  is  pain,  morphine  is  the  best  hypnotic, 
but  in  neurosis  and  mental  restlessness  the  bromides 
alone  or  in  combination  with  chloral  are  better  and  safer. 

The  bromides  of  Potassium,  Sodium,  and  Ammonium 
(gr.  X  of  each)  with  ii\xx  of  Sal  Volatile  and  Chloric  Eiher 
and  1)1^  iij  of  dilute  Hydrocyanic  Acid  in  5  3  of  Pepj  srmint 
water  make  a  good  combination. 

8 


114  Treatment 

The  peculiar  watchfulness,  apprehension,  and  intrusion 
of  unwelcome  ideas  associated  with  the  restlessness  from 
high  arterial  tension  should  be  distinguished  from  the 
persistence  of  grief,  worry,  or  anxiety  which  may  be  a 
direct  preventive  of  sleep,  and  call  for  such  a  nerve  seda- 
tive as  that  just  mentioned,  whereas  the  other  does  not. 

A  review  of  the  numerous  hypnotic  preparations  with 
their  special  uses  would  be  a  more  elaborate  matter  than 
is  here  contemplated,  but  it  may  be  suggested  that  when 
sleeplessness  is  associated  with  neuralgic  pain,  Antipyrin, 
Butyl  Chloral,  or  Chloretone  in  5-15-grain  doses  is 
indicated.  In  neurasthenic  conditions,  Chloralamide, 
Sulphonal,  Trional  or  Tetronal  in  doses  of  about  20  grains 
should  be  given  in  cachet,  or  dissolved  in  spirit  and  hot 
water.  The  combination  of  equal  quantities  of  sulphonal 
and  bromide  of  potassium  is  specially  effective.  Hedonal 
in  cachet  of  8-15  grains  is  useful  under  similar  circum- 
stances, and  Urethane,  which  is  readily  soluble,  may  be 
given  in  5-15-grain  doses  to  children  or  subjects  of 
mania,  being  specially  devoid  of  danger. 

As  general  hypnotics  which  are  free  from  disagreeable 
effects,  Proponal  and  Veronal  in  doses  of  7  grains  or  more 
are  to  be  recommended,  and  Dormiol  in  gelatine  capsules 
containing  a  similar  amount  is  effective.  As  a  substitute 
for  opium  and  morphine.  Codeine  or  Heroine  can  be 
used  ;  they  are  specially  useful  where  there  is  irritable 
cough,  and  the  last  need  be  given  only  in  very  smaU 
quantities  such  as  -^j  grain.  Paraldehyde  is  almost 
the  only  soporific,  if  we  except  alcohol,  which  can 
be  regarded  as  rather  stimulant  in  its  action,  and 
is  safe  and  specially  useful  in  organic  heart  and  kidney 
disease,  often  promoting  diuresis,  and  in  asthma  and 
arterio-sclerosis  tending  to  diminish  spasm.  Prepara- 
tions of  lettuce  and  hops,  not  omitting  the  "  hop- 
pillow,"  may  be  suggested  in  what  may  be  termed  fanciful 
insomnia,  and  in  weaning  patients  from  the  habitual 


Narcolepsy  115 

use  of  hypnotic  drugs  sugar  of  milk  increasingly  sub- 
stituted is  a  convenient  agent. 

Nareolepsy. — This  state  may  be  regarded  as  the 
antithesis  of  insomnia,  one  term  indicating  inability  to 
sleep,  the  other  inability  to  keep  awake. 

The  feeling  of  drowsiness  is  irresistible,  continuing 
day  and  night,  so  that  the  subject  may  even  sleep  standing 
or  walking,  and  it  requires  considerable  physical  disturb- 
ance to  rouse  the  patient :  in  this  resembling  the  condition 
produced  by  narcotic  poisons. 

The  affection  is  uncommon  and  usually  temporary, 
occurring  for  the  most  part  in  young  women,  apparently 
as  a  result  of  auto-intoxication  from  the  defective  meta- 
bolism of  proteids  associated  with  constipation. 

The  remedy  consists  in  abstinence  from  meat  and 
reduction  in  nitrogenous  food  generally,  while  securing 
regular  action  of  the  bowels  and  suitable  exercise. 

Cephalalg^ia. — Headache  is  often  a  prominent 
feature  in  febrile  states,  anaemia,  renal  disease  and  arterio- 
sclerosis, and  is  specially  severe  in  intra-cranial  diseases 
such  as  meningitis,  cerebral  softening,  tumour,  or  abscess. 
Under  these  circumstances  it  is  persistent  and  associated 
with  other  manifestations  which  incapacitate  the  patient, 
and  render  the  underlying  state  evident  on  careful 
investigation.  Perhaps  the  least  obvious  of  these  causes 
is  chronic  Bright's  disease,  in  which  the  headache  is 
commonly  of  a  dull  heavy  character,  located  especially  in 
the  occipital  region  extending  to  the  back  of  the  neck.  It 
occurs  on  waking  in  the  morning,  and  is  often  accompanied 
by  vertigo,  and  in  advanced  cases  temporary  aphasia  and 
failing  sight.  A  persistent  headache  with  these  char- 
acteristics, particularly  in  an  individual  at  or  past  middle 
life,  should  always  suggest  an  examination  of  the  urine. 

Excluding  serious  disease,  in  which  headache  is  merely 
a  painful  incident,  there  are  a  number  of  causes  producing 
this  trouble  in  persons  of  all  ages  who  are  otherwise  in 


1 1 6  Cephalalgia 

relatively  sound  health.  It  is  only  necessary  to  mention 
among  these  the  effect  of  a  close  atmosphere  with  over- 
crowding, a  frequent  cause  of  headache  associated  with 
attending  places  of  worship  or  amusement,  or  resulting 
from  sitting  or  sleeping  in  small  ill-ventilated  rooms — a 
common  practice  in  towns  of  closing  windows  and  even 
chimneys  to  exclude  dust  and  soot  contributing  very 
materially  to  this.  Wearing  a  heavy,  hot,  or  ill-fitting 
hat  for  hours  at  a  time,  in  men,  and  a  close  arrangement 
of  super-abundant  hair  in  women,  are  provocative  of  this 
symptom,  and  on  the  other  hand  with  insufficient  covering, 
exposure  of  the  scalp  either  to  heat  or  cold,  as  in  sitting 
under  a  lamp  or  in  a  draught,  has  a  similar  effect. 
Habitual  breathing  by  the  mouth  instead  of  by  the  nose 
is  also  productive  of  headache,  as  is  seen  constantly  in 
cases  of  adenoid  growths,  obstructed  nostrils,  and  en- 
larged tonsils.  Besides  the  inhalation  of  products  of 
respiration,  or  coal  gas,  emanations  from  drains  and  such 
vapours  as  nitrite  of  amyl,  ammonium  sulphide,  sul- 
phuretted hydrogen,  and  other  chemical  or  putrefactive 
vapours  are  similarly  productive  of  pain  referred  to  the 
head  with  giddiness  and  nausea. 

In  a  state  of  health  the  brain  appears  to  be  insensitive  ; 
but  as  in  the  case  of  ligaments  and  tendons,  acute 
sensibility  may  develop  in  connection  with  inflammation 
or  tension.  Pain  in  the  head  may  therefore  reasonably  be 
ascribed  directly  to  the  brain  when  intra-cranial  tension 
is  increased  by  undue  vascularity  or  exudation  with 
ventricular  distension. 

Inflammatory  states  of  the  membranes,  as  in  menin- 
gitis, areproductive  of  acute  suffering,  and  vascular  disease, 
whether  acute  as  in  syphilitic  arteritis,  or  degenerative 
as  in  senile  atheroma,  is  also  usually  accompanied  by 
aching  in  the  head,  which  may  precede  apoplexy  or 
thrombosis. 

In   addition  to  intra-cranial  changes,  disturbances  in 


Persistent  Headache  117 

the  nerves  of  the  scalp  also  lead  to  pain  and  tenderness 
referred  to  the  head,  either  in  actual  fibrositis  or  neuritis 
with  soreness  along  the  course  of  the  nerves  or  in  neuralgia 
with  intermittent  pain  referred  to  their  areas  of  distribu- 
tion, and  tender  spots  at  points  of  emergence  through 
bone  or  fascia. 

In  addition  to  these  sources  of  headache,  others  of 
more  general,  vague,  or  transitory  occurrence  are  attri- 
buted to  "  toxaemia "  and  vascular  spasm,  associated 
probably  with  irregular  blood  supply  causing  anaemia  or 
flushing  of  particular  areas. 

Pain,  with  more  restricted  distribution,  and  greater 
intensity  and  persistence,  may  be  associated  with  abscess, 
aneurysm,  new  growth,  or  nodes. 

From  the  practical  pointof  viewof  diagnosis,  prognosis, 
and  treatment,  headache  may  be  considered  as  persistent, 
periodically  recurring,  and  occasional  :  its  causation  being 
more  or  less  definitely  established  in  this  order.  That 
is  to  say,  a  persistent  headache  is  usually  due  to  organic 
disease,  either  within  the  cranium  or  in  some  important 
organ  elsewhere.  Within  the  cranium  such  conditions 
as  meningitis,  concussion,  abscess,  tumour,  and  arterial 
degeneration  or  thrombosis  may  be  instanced,  the  pain 
being  in  many  instances  localised  either  about  the  ear  or 
occiput,  usually  very  severe  and  subject  to  exacerbations. 

The  consideration  of  severe  and  persistent  headache 
due  to  organic  disease  within  the  cranium  will  not  be 
entered  upon  here,  except  to  point  out  the  great  import- 
ance of  its  early  recognition,  which  may  be  aided  by  the 
occurrence  of  impromptu  vomiting,  altered  reflexes, 
constant  vertigo,  and  the  presence  of  optic  neuritis, 
paralysis  of  cranial  nerves,  marked  increase  of  pain  on 
coughing,  stooping,  or  lying  down,  and  other  evidence  of 
intra-cranial  pressure. 

The  opportunity  must  be  taken  also  of  pointing  out 
the   imperative    duty   of    applying   such    anti-syphilitio 


ii8  Organic  Causes 

remedies  as  mercury,  the  green  iodide  especially,  and 
iodide  of  potassium  in  large  doses,  since  a  considerable 
proportion  of  such  cases  prove  amenable  to  this  treatment. 
Where  no  relief  follows  and  the  presence  of  syphilis  is 
excluded,  recourse  must  be  had  to  such  drugs  as  Acetani- 
lid  in  doses  from  2  to  15  grains,  Exalgine  2  to  5  grains, 
or  Morphine  in  adequate  amount  to  subdue  the  pain  ; 
while  considering  the  advisabihty  of  surgical  measures. 

Causes  outside  the  cranium  are  for  the  most  part 
changes  in  the  blood-stream,  either  in  the  direction  of 
variations  in  quality,  quantity,  or  pressure,  or  the 
presence  of  injurious  matters  resulting  from  morbid 
processes  within  the  body,  or  introduced  from  without ; 
to  v/hich  may  perhaps  be  added  impressions  conveyed 
through  the  nervous  system  in  chronic  disease  of  the 
pelvic  organs  from  which  the  former  cannot  be  traced. 

Persistent  headache  should  therefore  lead  to  a  sys- 
tematic examination  with  a  view  to  the  discovery  of  such 
organic  disease,  and  the  reUef  of  the  headache  should 
be  looked  for  in  the  remedy  of  the  primary  malady, 
rather  than  in  the  apphcation  of  anodyne  measures 
ad  hoc. 

The  discrimination  of  these  various  causes  of  headache 
is  no  easy  matter,  and  when  decided  upon  alleviation  is 
not  always  readily  obtained.  To  consider  first  ab- 
normalities of  the  circulation.  These  include  excess  or 
diminution  in  the  quantity  of  blood  distributed  to  the 
head,  which  is  commonly  apparent  in  the  colour  of  the 
face  and  neck,  and  is  further  characterised  by  suffusion 
of  the  conjunctiva  and  a  sense  of  throbbing,  with  exacerba- 
tion of  pain  on  stooping  or  in  the  horizontal  position 
when  due  to  overfulness  of  the  vessels. 

This  form  of  headache  accompanies  plethora,  fever, 
alcoholic  stimulation,  and  the  effect  of  drugs  which  excite 
circulatory  activity  in  more  than  a  moderate  degree,  such 
as  the  vascular  dilators  and  tonics,  and  commonly  accom- 


Treatment  119 

panies  palpitation  of  the  heart  from  excitement,  exertion, 
or  disturbance  of  digestion. 

The  vascular  dilatation  and  tension  may  be  either 
active  and  arterial  or  passive  and  venous.  The  former 
rules  in  Grave's  disease,  fever,  plethora,  and  stimulation, 
and  the  latter  in  mediastinal  pulmonary  or  cardiac  disease 
— chiefly  of  the  mitral  valve — associated  with  obstruction 
to  the  circulation  and  dilatation  of  the  right  cavities 
of  the  heart ;  though  undue  constriction  of  the  neck  or 
waist  by  tight  clothing  may  have  a  similar  effect. 

Headache  occurs  in  both  conditions,  but  is  more 
definitely  throbbing,  accompanied  by  visible  pulsation  of 
the  temporal  and  other  superficial  arteries  and  fiushing 
of  the  face  in  the  active  form,  while  a  dull  aching  and 
tendency  to  cyanosis  with  fulness  if  not  actual  puffiness 
of  the  face  characterises  the  passive.  In  either,  lowering 
the  head,  whether  in  lying  down  or  stooping,  and  cough 
increase  the  pain,  and  may  be  accompanied  by  vertigo 
and  a  sense  of  fulness. 

The  treatment  of  headache  associated  with  congestion 
is  necessarily  bound  up  with  that  of  the  more  general 
condition. 

Purgatives  are  valuable  in  both  the  active  and  passive 
forms,  particularly  sahnes  and  the  aperient  mineral 
waters  in  combination  with  small  doses  of  calomel  or 
mercury.  In  arterial  hyperaemia  and  over-activity  of 
the  heart  it  may  be  advisable  to  give  small  doses  of 
such  depressants  as  antimony,  aconite,  and  iodide  of 
potassium,  the  latter  especially  in  gouty  conditions. 

In  the  passive  form  of  venous  congestion,  benefit  is 
more  likely  to  be  obtained  by  digitalis  or  strophanthus. 
But  in  either,  opium  and  its  derivatives  are  contra, 
indicated,  and  strychnine  usually  increases  the  headache, 
as  do  the  vascular  dilators,  though  either  may  be  needed 
for  their  general  effects. 

In  febrile  affections  and  vascular  excitement  associated 


1 20  Treatment 

with,  headache,  great  relief  is  often  afforded  by  cold  to 
the  head — which  is  most  effectually  applied  in  the  form 
of  an  indiarubber  bottle  filled  with  iced  water  or  shaved 
ice,  wrapped  in  a  towel  and  placed  under  the  nape  of  the 
neck.  It  is  more  constant  in  its  effect  than  either  eva- 
porating lotion  or  an  icebag,  acting  as  a  sedative  to  the 
circulation  and  reducing  fever. 

When  the  pain  in  the  head  is  very  acute,  especially 
when  inflammatory  in  origin,  the  application  of  one  or 
two  leeches  below  or  behind  the  ear  has  often  the  speediest 
effect  in  relieving  it,  while  for  milder  cases  the  hot  mustard 
and  water  footbath  is  beneficial. 

There  are  instances  in  plethoric  and  gouty  subjects 
where  headache  is  so  intense  that  the  patient  loses  control 
of  himself,  and  in  such,  the  removal  of  20  to  30  ounces 
of  blood  by  venesection  is  necessary,  and  affords  the 
most  rapid  means  of  relief.  This,  combined  with  full 
doses  of  iodide  of  potassium  and  saline  purgatives,  sub- 
dues the  pain  at  the  time,  but  subsequent  attacks  will 
occur  unless  restraint  in  food  and  stimulants  is  practised. 

In  the  opposite  direction  of  anaemia,  whether  primary 
or  secondary,  headache  is  of  very  much  more  frequent 
occurrence,  and  the  altered  conditions  of  the  blood  make 
it  practically  impossible  to  decide  whether  the  deficiency 
in  the  normal  constituents  or  the  presence  of  abnormal 
ones  is  the  more  important  factor.  But  undoubtedly 
the  most  constant  complaints  of  headache  come  from 
young  women  suffering  from  chlorosis  with  gastric  sym- 
ptoms and  constipation,  where  these  states  are  combined  ; 
though  simple  oligsemia  from  recent  haemorrhage  is  also 
productive  of  the  symptom,  sometimes  in  an  acute 
degree. 

In  the  latter  instances,  the  preparations  of  opium, 
especially  morphia,  so  generally  given  to  combat  the 
circulatory  and  nervous  excitement  attending  serious 
haemorrhage,  appear  to  control  the  headache  also,  or  at 


Recurring  Headache  121 

least  to  produce  a  state  of  quiescence  which  mitigates 
the  suffering. 

For  the  most  part  in  anaemia  the  physician  is  chiefly 
concerned  in  restoring  the  blood  to  a  normal  condition, 
and  the  remedies  applied  for  this  purpose,  principally 
arsenic  and  iron  in  one  form  or  another,  with  suitable 
laxatives  and  graduated  diet,  ultimately  remove  the 
headache. 

Temporary  exacerbations  are  often  benefited  by  light 
nourishment  or  reheving  the  bowels  or  by  one  of  the 
drugs  recommended  in  the  paroxysmal  form  of  headache, 
to  be  presently  considered.  In  those  too-common  in- 
stances where  gastric  disturbance  with  vomiting,  and  even 
hsematemesis,  render  the  administration  of  most  drugs  by 
the  mouth  unsatisfactory,  chloretone  in  5-grain  doses,  in 
cachet  or  petroleum  emulsion,  may  prove  of  service,  but 
this  failing  a  hypodermic  injection  of  morphine  is  the 
most  effective  remedy. 

Periodically  recurring  headache  is  apparently  func- 
tional— that  is,  associated  rather  with  physiological  than 
anatomical  changes.  The  most  familiar  examples  are 
migraine,  clavus,brow  ague,  tic  douloureux,  andneuralgia. 
It  cannot  be  said  that  there  is  any  marked  regularity  in 
this  periodicity  except  in  the  case  of  brow  ague  and 
neuralgia,  which  may  keep  time  by  the  clock  ;  but  the 
recurrence,  though  irregular  in  time,  is  marked  by  close 
similarity  in  the  site  and  character  of  the  pain  though 
there  may  be  variations  in  severity,  and  subsidence 
between  the  attacks  is  complete. 

Hemiepania. — This  paroxysmal  complaint,  the 
leading  feature  of  which  is  one-sided  headache,  whence 
it  derives  this  name  or  the  abbreviated  one  of  migraine  or 
megrim,  is  essentially  a  functional  disease.  There  is  no 
ascertained  morbid  anatomy,  it  arises  and  subsides  in  an 
otherwise  healthy  subject,  and  in  the  intervals  of  the 
attacks  there  is  usually  perfect  health.     In  these  respects 


1 22  Hemicrania 

the  analogy  is  very  close  with  epilepsy,  the  one  being 
a  sensory  and  the  other  a  motor  disturbance.  Either 
complaint  is  most  apt  to  commence  soon  after  puberty, 
the  paroxysms  acquiring  a  regular  periodicity  or  being 
determined  by  some  unusual  strain  or  excitement. 

The  degrees  of  migraine  attacks  in  respect  of  frequency 
and  severity  have  a  close  parallel  with  those  of  epilepsy, 
in  which  the  haut  mat  and  'petit  mal  are  commonly  dis- 
tinct, the  one  being  characterised  by  severity,  and  the 
other  by  frequency  of  occurrence,  while  each  remains  for 
the  most  part  habitual  in  the  same  individual. 

There  is  a  further  similarity  in  that  either  paroxysm 
is  usually  inaugurated  by  minor  nervous  disturbances 
termed  the  "  aura,"  and  often  preceded  by  an  altered 
disposition  or  diffuse  sensation  appreciable  by  the  patient 
and  referable  possibly  to  altered  vascular  tension  due  to 
the  presence  of  some  toxic  material  in  the  blood.  Ex- 
ceptional cases  have  been  met  with  in  which  motor  and 
sensory  attacks  have  occurred  alternately  or  where  one 
has  supervened  on  the  other,  but  these  are  so  rare  as  to 
suggest  coincidence  rather  than  consequence,  and  do  not 
excite  any  anxiety  that  the  subject  of  migraine  may 
become  epUeptic. 

It  has  been  suggested  that  spasmodic  contraction  of 
a  cerebral  artery  might  account  for  an  epileptic  attack, 
which  is  sometimes  unilateral  or  at  least  unequally  deve- 
loped on  the  two  sides,  the  motor  manifestations  in  this 
pointing  to  the  middle  cerebral  artery  as  the  seat  of  dis- 
turbance. The  region  concerned  in  the  manifestations 
of  migraine,  particularly  the  evidence  of  disturbed  function 
in  the  abdominal  viscera,  points  to  the  distribution  of  the 
anterior  cerebral  artery  to  the  inner  surface  of  the  hemi- 
sphere forming  the  sides  of  the  longitudinal  fissure,  the 
terminal  portion  corresponding  to  the  visual  area,  in 
which  the  change  usually  commences.  Both  in  epilepsy 
and  migraine  the  onset  is  attended  with  pallor  of  the  face, 


Hemicrania  123 

suggesting  contraction  of  the  arterioles,  which  is  appar- 
ently of  brief  duration,  being  followed  by  dilatation  and 
flushing  of  the  corresponding  areas.  It  may  be  this 
restoration  of  the  circulation,  rather  than  the  initial 
contraction  of  arteries,  which  brings  about  the  severe 
headache  and  visceral  disturbance  which  quickly  succeed 
the  inaugural  symptoms,  very  much  as  the  restoration 
of  circulation  in  the  nerves  and  tissues  of  the  extremities 
after  prolonged  exposure  to  cold  or  pressure  is  associated 
with  acute  aching. 

An  attack  of  migraine  is  preceded  in  many  individuals 
by  a  feeHng  of  vigour  and  mental  activity  due  to  rising 
arterial  tension,  lasting  an  hour  or  two,  and  then  giving 
way  'to  the  recognised  aura.  This,  which  corresponds 
to  commencing  arterial  spasm  and  anaemia  of  the  affected 
portion  of  the  cortex,  takes  the  form  of  a  central  scotoma 
in  the  visual  field,  so  that  the  patient  is  unable  to  see 
the  point  of  his  pen,  the  words  he  is  reading,  or  the  face 
of  the  person  he  may  be  talking  to,  though  surrounding 
objects  not  exactly  in  the  central  point  of  vision  may  be 
as  clear  as  usual.  Peripheral  vision,  however,  is  interfered 
with  by  the  appearance  of  "  zig-zags  "  or  "  Hues  of  forti- 
fication," as  they  have  been  called,  plain  or  coloured, 
and  black  spots.  These  phenomena  are  quite  transitory, 
and  as  they  subside  in  the  course  of  a  few  minutes  to  half 
an  hour,  the  characteristic  one-sided  headache  develops, 
rapidly  acquiring  great  intensity  and  concentrating  on 
the  eyeball  and  corresponding  mastoid  region,  though 
extending  vaguely  to  the  brow,  temple,  and  occiput. 
Meanwhile  the  countenance  becomes  pale,  the  temporal 
arteries  hard  and  small,  and  the  intelligence  clouded,  the 
patient  feeling  bewildered,  prostrated,  and  often  faint, 
so  that  he  is  compelled  to  lie  down. 

Considerable  variations  occur  in  different  people,  the 
visual  aura  being  sometimes  more  complex  and  ideational, 
or  other  special  sense  being  concerned  such  as  the  auditory. 


1 24  Hemicrania 

but  commonly  the  aura  assumes  very  much  the  same 
character  in  the  same  person  with  subsequent  attacks, 
though  producing  less  impression  as  f  amiharity  is  acquired. 
The  growing  intensity  of  the  hemicrania  is  attended  with 
a  condition  allied  to  collapse  with  moist  skin,  chilliness, 
muscular  and  nervous  prostration,  and  soon  a  sensation 
of  nausea  attended  in  most  cases  by  actual  retching. 
Any  food  which  has  been  recently  taken  is  ejected  prac- 
tically unchanged,  but  the  vomited  matter  consists 
mainly  of  mucus,  bile,  and  watery  fluid  containing  organic 
acids.  Though  the  act  of  vomiting  is  distressing,  some 
relief  usually  follows,  but  the  headache  continues,  the 
patient  becomes  more  apathetic,  resents  any  disturbance, 
avoids  light  and  noise,  dozing  and  then  sleeping  except  when 
roused  by  the  profuse  secretion  of  pale  limpid  urine  which 
occurs  for  some  hours  in  the  later  phase  of  the  attack. 

During  the  early  part  of  the  paroxysms  the  mouth 
is  dry,  there  is  complete  anorexia,  the  stomach  rejecting 
any  food  or  even  Kquid  that  may  be  taken,  and  there 
is  arrest  of  bile  secretion  judging  by  the  occurrence  of 
flatulence  and  pale  faeces.  These  indications  of  marked 
nervous  disturbances  in  the  secretory  organs  are  accom- 
panied also  by  partial  suppression  of  urine,  though 
diuresis  is  the  first  function  to  be  re-established.  The 
entire  attack  usually  lasts  six  to  twelve  hours,  but  as  it 
commonly  commences  in  the  early  part  of  the  day  the 
patient  is  unfit  for  anything  till  after  a  night's  rest  and 
the  re-estabhshment  of  the  digestive  functions  next  morn- 
ing. Curiously,  in  this  complaint,  though  the  malady  is 
distressing  and  incapacitating  while  it  lasts  and  the 
subject  of  it  quite  unable  to  take  or  digest  any  food  for 
twenty-four  hours,  the  usual  or  even  an  improved  feehng 
of  health  is  immediately  restored  when  it  subsides.  As 
far  as  can  be  judged  the  incidence  and  recurrence  of 
migraine  are  associated  with  exhaustion  of  the  nerve 
centres.     The  disorder  commences  most  often  in  connec- 


Hemicrania  125 

tion  with  severe  study,  deprivation  of  sleep,  anxieties  or 
excessive  social  excitement,  and  recurs  with  a  kind  of 
periodicity  which  may  nevertheless  have  some  relation  to 
causes  of  nerve  exhaustion,  disturbance  of  digestion,  or 
menstruation. 

The  attacks  usually  become  less  frequent  towards 
middle  life,  the  intervals  becoming  longer  and  the 
seizures  themselves  less  severe,  but  it  is  difficult  to  esti- 
mate when  they  cease,  and  in  some  instances  they  con- 
tinue into  old  age,  this  being  itself  an  indication  that 
they  exert  no  influence  in  shortening  life  or  introducing 
other  complaints,  being  indeed  quite  compatible  with 
sound  health  and  long  life. 

All  do  not  suffer  to  the  extent  indicated  in  the  above 
description,  and  for  the  most  part,  after  the  first  few 
seizures,  there  is  some  mitigation  and  shortening  of  them, 
also  the  attacks  appear  to  be  less  severe  as  they  are  more 
frequent,  so  that  many  who  experience  them  once  or 
twice  a  week  escape  with  merely  a  headache  and  loss  of 
appetite  for  a  few  hours,  and  are  often  capable  of  carrying 
on  routine  work. 

In  the  most  typical  cases  the  tendency  to  migraine 
appears  to  be  hereditary  and  spontaneous  ;  though  per- 
haps accentuated  by  some  general  interference  with 
robust  health,  such  as  sometimes  accompanies  the  adop- 
tion of  serious  studies,  or  the  responsible  duties  of  life 
particularly  in  cities  :  for  it  has  been  noted  that  the 
bucoUc  temperament  is  seldom  associated  with  the  com- 
plaint, and  a  free  open-air  Kfe  is  often  enough  to  effect 
a  cure  in  those  who  are  subject  to  it.  In  more  pronounced 
cases  the  attacks,  like  those  of  asthma,  commence  in  late 
childhood  or  soon  after  puberty,  and  may  be  more  fre- 
quent or  severe  and  less  amenable  to  treatment. 

It  is  necessary,  however,  to  state  that  a  very  consider- 
able number  of  individuals  apparently  become  subject 
to  attacks  of  migraine  without  hereditary  predisposition. 


126  Treatment 

and,  maybe,  at  a  later  period  of  life,  as  a  result  of  some 
local  injury  or  disorder,  the  attacks  being  generally  very 
similar,  but  wanting  in  some  particulars.  These  have 
been  aUuded  to  as  "  reflex  migraine."  Such  are  com- 
monly associated  in  women  with  menstruation  and 
chronic  disease  of  the  pelvic  organs,  and  have  in  both 
sexes  followed  on  head  injuries,  chronic  inflammatory 
conditions  of  the  appendix,  gaU  bladder,  stomach  and 
other  abdominal  viscera.  The  attacks  associated  with 
organs  of  special  sense  such  as  errors  of  refraction  may 
also  be  regarded  in  this  Hght. 

The  importance  of  being  on  the  alert  to  recognise  this 
aspect  of  the  case  Hes  in  the  fact  that  the  cure  of  the  local 
lesion,  where  possible,  is  the  most  direct  road  to  recovery, 
and  may  be  the  more  wilHngly  undertaken,  even  by 
surgical  means,  since  the  migraine  is  often  not  the  only 
manifestation,  though  the  most  obvious  to  the  patient, 
and  may  lead  to  the  discovery  of  chronic  or  progressive 
disease  which  undermines  the  patient's  health  generally, 
and  may  even  prove  ultimately  fatal. 

The  great  difficulty  in  the  treatment  of  migraine  hes 
in  the  uncertainty  of  its  periodicity,  so  that  it  is  almost 
impossible  to  be  beforehand  with  remedies,  while  on  the 
other  hand  when  once  the  attack  is  estabhshed,  absorption 
from  the  stomach  ceases  and  internal  remedies  then  have 
Httle  or  no  effect.  At  the  very  commencement,  during 
the  stage  of  vascular  contraction,  and  before  the 
headache  has  definitely  commenced,  the  following 
mixture  may  arrest  the  attack  ; 

^.  Liq.  Trinitrini  .  •  .  .  ni  i] 
Acid.  Hydrobrom.  dil.  .  .  ,  nt  xx 
Aquam  ...  ad  §  ss 

Twice,  with  one  hour  interval. 

If  taken  as  early  as  possible  when  the  onset  is  threat- 
ened  or   recognised,  there   are  three  drugs  which  may 


Treatment  127 

mitigate    the    severity    of    the    paroxysm.     These    are 
phenacetin,  phenazone,  and  chloretone. 

On  account  of  their  depressing  effect  the  two  former 
drugs  are  usually  combined  with  caffeine  citrate. 

^.  PheDacetin       .        .    gr.  x        I        '^.  Phenacetin       .        .    gr.  x 
Caffein.  cit.     .        .     gr.  v        I  Butyl  Chloral.    .        .    gr.  z 

^.  Antipyrin      .        .    gr.  x 
Caffein.  cit.  .        .    gr.  v 
In  cachet  or  as  a  powder. 

Half  as  much  again  may  be  taken  as  a  single  dose 
on  a  subsequent  occasion  if  this  does  not  prove  effective 
in  the  first  attack,  but  it  should  not  be  repeated.  Migra- 
nin  (Antipyrin  Caffeino-citricum)  in  8  to  15-grain  doses 
may  prove  of  service  if  this  fails  and  has  the  advantage 
of  being  freely  soluble  and  consequently  more  readily 
absorbed. 

Phenacetin  may  also  be  conveniently  given  as  tho 
granulated  effervescent  salt  containing  5  grains  in  the 
drachm. 

Chloretone,  which  is  a  comparatively  new  drug  and  not 
very  soluble  in  water,  may  be  taken  in  doses  of  10  to  15 
grains  in  powder  or  cachet  under  similar  circumstances. 
The  effect  of  these  remedies  may  be  to  add  to  the 
prostration  which  naturally  accompanies  the  complaint 
and  may  in  addition  induce  diaphoresis  and  sometimes 
vertigo,  so  the  patient  should  remain  quiet  and  preferably 
recumbent  while  under  their  influence. 

No  food  should  be  taken  while  the  attack  lasts. 
Usually  there  is  no  inchnation  for  it,  but  sohcitous  re- 
latives have  often  a  mistaken  idea  about  maintaining 
the  strength  in  any  illness.  It  is  a  pecuharity  of  this 
complaint  that  exhaustion  does  not  follow  the  short 
abstinence,  and  when  the  seizure  has  passed  off  the 
appetite  and  power  of  digestion  and  assimilation  are 
restored  at  once.  The  only  thing  at  all  acceptable  is  tea, 
which  may  be  taken  at  intervals  according  to  inclination 


128  Treatment 

and  in  stronger  infusion  than  usual.  At  the  end  of  the 
attack,  a  cup  of  soup  or  of  milk  arrowroot  or  gruel  with 
a  Httle  spirit  may  be  taken  before  retiring  for  the  night, 
if  the  patient  feels  equal  to  it. 

In  the  more  frequently  repeated  but  less  severe 
attacks  in  which  prolonged  headache  is  the  leading 
symptom  the  following  combination  of  drugs  is  often 
beneficial  : 

1^.  rhenazoni  e        .         "j 

Ammon.  Broraidi     .         .  r  aa  gr.  x 

Sod.  fc^alicylatis        .        .         J 
Aq.  Camphorse  .        .        .        ad  §  j 

Every  two  hours  till  four  doses  have  been  taken. 

When  the  intervals  between  the  attacks  are  long, 
three  to  six  months  or  more,  it  is  hardly  to  be  expected 
that  patients  will  adhere  to  irksome  precautionary  mea- 
sures, beyond  partial  relaxation  of  mental  application, 
paying  attention  to  the  regularity  of  the  bowels,  and 
perhaps  increasing  somewhat  the  daily  allowance  of  fluid  ; 
but  when  seizures  occur  at  shorter  intervals — and  they 
may  do  so  more  than  once  in  a  week — it  is  essential 
to  secure  mental  rest  for  a  time  and  a  more  open-air  life 
while  taking  regularly  fractional  doses  of  calomel  followed 
by  saline  laxatives.  A  generous  diet  is  advocated  with 
sufficient  vegetables  and  fruits,  and  for  a  few  weeks  at 
all  events  such  nerve  tonics  as  quinine  and  guarana. 

5i.  Quinin.  Muriat        .         .        gr.  ij 
Tinftt.  GuarauEe       .         .  5ss 

Acid.  Hydrobrom.  dil.  .  ill  xx 
Aq.  Chlorof  ormi  .  .  ad  §  j 
Three  times  a  day  before  meals. 

It  is  advisable  also  to  look  for  and  if  necessary  correct 
any  local  source  of  nerve-strain  or  irritation  such  as  error 
of  refraction  or  disease  in  the  teeth  or  nose  ;  though  this 
does  not  necessarily  at  once  abolish  the  attacks.  These 
appear  to  be  precipitated  by  some  special  cause  of  nervous 


Clavus  Hystericus  119 

exhaustion  associated  with  general  depression  of  health, 
and  it  is  this  which  so  often  determines  a  seizure  at  some 
critical  and  most  inconvenient  time,  such  as  the  period 
of  an  examination,  of  some  particular  social  engagements, 
or  perhaps  the  eve  of  a  journey,  when  extra  demand  is 
made  on  the  nervous  system. 

Clavus  Hysterieus. — This  is  usually  described  as 
an  intense  boring  pain  in  one  temple,  the  vertex,  or 
occiput,  occurring  from  time  to  time  in  women  who  are 
the  subjects  of  other  hysterical  manifestations  such  as 
the  globus  hystericus,  emotional  attacks,  and  hysteroid 
convulsions,  one  or  other  of  which  paroxysms  it  usually 
succeeds.  From  the  written  descriptions  in  most  of  the 
older  text-books,  it  would  appear  that  this  particular 
form  of  headache  and  the  more  active  hysterical  com- 
plaints with  which  it  was  associated  were  of  commoner 
occurrence  in  former  generations  than  at  present,  when  the 
passive  form  of  neurasthenia  prevails. 

Such  a  local  headache  must  be  regarded  and  treated 
as  part  of  the  general  complaint.  It  is  transitory  and  is 
best  met  by  a  mixture  containing  Bromide  of  Potassium 
gr.  XX,  and  Ammoniated  Tincture  of  Valerian  5  j  in 
camphor-water,  though  the  combination  of  Phenacetin 
gr.  X  and  Citrate  of  Caffeine  gr.  v  has  a  more  imme- 
diate effect.  Seclusion  and  quiet  are  of  chief  importance 
until  the  pain  subsides,  and  it  is  well  to  be  on  guard 
against  hasty  recourse  to  opiates,  as  in  such  cases  the 
opium  habit  is  peculiarly  liable  to  be  acquired,  and,  at 
the  best,  frequent  repetitions  of  the  sedative  are  likely 
to  be  called  for. 

The  pill  of  Butyl  Chloral  Hydrate  gr.  iij  made  up 
with  Glycerine  of  Tragacanth  and  perhaps  with  2W  gr. 
of  Gelseminine  Hydrochloride  is  also  useful. 

Bpow  Ag'ue,  which,  as  its  name  implies,  affects  the 
supra-orbital  nerve  in  those  who  are  the  subjects  of 
malaria,  is  a  very  intense  form  of  neuralgia  recurring  at 

9 


130  Tic  Douloureux 

definite  intervals  for  a  number  of  successive  days  at  the 
same  hour.  It  may  be  either  intermittent  or  remittent, 
and  at  its  worst  is  so  severe  as  to  exceed  the  Hmits  of 
seK-control  which  can  be  exercised  by  the  patient ;  and 
raises  suspicion  of  tic  douloureux  or  organic  disease. 
The  patients  are  commonly  anaemic  and  debilitated, 
and  the  complaint  may  be  identified  by  its  periodicity 
and  the  history  of  exposure  in  malarial  districts.  -The 
two  drugs  most  efiective  as  remedies  are  quinine  and 
arsenic,  which  must  be  quickly  raised  to  full  dosage  and 
given  for  some  days,  till  the  pain  entirely  ceases  to 
recur. 

Instances  in  Great  Britain  are  exclusively  met  with 
in  foreigners  or  those  who  have  resided  abroad,  and  being 
of  rare  occurrence,  are  hable  to  be  overlooked.  I  can 
recaU  a  good  example  in  a  Pole  who  on  account  of  tne 
great  severity  of  the  attacks,  which  resisted  the  ordina-iy 
remedies,  was  about  to  be  trephined  as  a  case  of  central 
tumour,  but  who  was  at  once  relieved  by  Liq.  Arsenicalia 
in  10-minim  doses.  TMien  the  attacks  recurred  eighteen 
months  later,  they  were  allayed  by  the  same  drug. 

Tie  Douloureux. — This,  the  most  intense  form  of 
neuralsia.  is  fortunately  very  rare.  It  has  been  dhserved 
in  elderly  people  and  has  been  associated  with  the  taint 
of  insanity.  It  is  remarkable  for  the  suddenness  and 
intensity  of  the  paroxysms,  lasting  from  a  few  seconds 
to  a  minute  at  a  time,  but  recurring  often  at  short  inter- 
vals . 

The  pain  is  accompanied  in  many  cases  with  muscular 
contractions,  lachrymation,  and  flushing  or  pallor  on  the 
affected  side  of  the  face  or  scalp.  It  quite  overcomes 
the  self-control  of  the  patient,  and  when  it  subsides 
leaves  him  in  a  shaken  and  apprehensive  state,  which 
has  culminated  in  some  instances  in  suicide. 

The  causation  of  the  malady  is  obscure,  but  those 
cases  in  which  foreign  bodies,  scars,  and  neuromata  have 


Tic  Douloureux  131 

been  discovered  in  association  with  the  fifth  or  other 
nerves,  and  whose  removal  has  been  attended  with  rehef, 
would  suggest  a  very  careful  search  for  any  lesion  of  the 
kind. 

The  condition  of  the  patient  is  so  pitiable  that  he  will 
submit  to  the  most  complex,  dangerous,  and  extensive 
operations  in  the  hope  that  either  death  or  cure  may 
terminate  his  sufferings  and  terrible  apprehension.  Many 
have  submitted  to  excision  of  nerves  and  to  removal  of 
Meckel's  or  the  Gasserian  ganglion  in  the  hope  of 
obtaining  relief. 

jMany  years  ago  an  elderly  man  under  the  care  of 
Mr.  Henry  IMorris  underwent  an  operation  for  division  of 
the  infra-orbital  nerve  at  the  back  of  the  orbit,  without 
avail ;  subsequently  in  the  course  of  an  examination  of 
the  mouth  prehminary  to  excision  of  the  superior  maxilla 
a  small  shotlike  body  beneath  the  mucous  membrane  of 
the  cheek  was  touched,  bringing  on  a  severe  paroxysm. 
The  removal  of  this  put  an  end  to  the  attacks. 

Other  cases  have  been  recorded  in  which  the  excision 
of  cicatrices  or  foreign  bodies  has  been  attended  with 
a  hke  result,  but  unfortunately  these  are  a  minority,  and 
in  most  instances  the  attacks  recur  in  spite  of  surgical 
treatment.  Recently  cases  have  been  benefited  by  the 
injection  of  osmic  acid  or  alcohol  into  the  affected  nerve. 

The  drugs  which  can  be  suggested  as  likely  to  be  of 
service  here  are  few.  Where  no  local  lesion  can  be  dis- 
covered, and  particularly  where  the  pain  is  not  limited  to 
the  distribution  of  a  single  branch  of  nerve,  arsenic  in  full 
doses  should  be  tried,  the  amount  being  raised  by  degrees 
to  15  or  even  20  minims  of  the  liquor  given  after  meals  and 
washed  down  with  a  good  quantity  of  fluid.  The  drugs 
employed  in  the  more  ordinary  forms  of  neuralgia  may 
be  given  in  full  doses,  especially  exalgin,  acetanilid,  and 
chloretone,  but  pending  more  definite  measures  recourse 
must  be  had  to  the  hypodermic  injection  of  morphine. 


13^  Neuralgia 

Neuralgia. — The  pain  arising  in  connection  with  the 
cranial  nerves  differs  from  headache  in  general  in  its  strict 
limitation  to  particular  branches,  more  especially  to  those 
of  the  fifth,  being  almost  always  limited  to  one  side. 
There  is  also  a  pecuhar  periodicity  in  the  attacks,  which 
tend  to  recur  at  the  same  hour  each  day.  The  character 
of  the  pain  is  less  dull  aching  than  penetrating  and  varied 
by  sudden  darting  or  shooting  pangs,  which  may  be  so 
sudden  and  severe  as  to  cause  involuntary  jerking  of  the 
head.  Another  characteristic  feature  is  the  presence  of 
painful  points,  apparently  located  in  the  regions  where 
the  nerve  in  its  course  perforates  resisting  structures 
such  as  bone  or  fascia,  these  points  being  tender  on 
pressure.  Neuralgia  is  very  much  more  frequently  asso- 
ciated with  anasmia  and  debihty  than  with  plethora  or 
even  a  normal  state  of  the  blood,  though  in  these  latter 
it  may  occur  as  a  result  of  inflammation  of  the  nerve 
sheath  and  fibrous  stroma  or  in  consequence  of  peripheral 
irritation. 

In  treating  neuralgia,  therefore,  these  possibihties 
should  be  borne  in  mind.  An  otherwise  healthy  indivi- 
dual may  develop  neuralgia  in  consequence  of  continued 
irritation  from  a  diseased  tooth,  sometimes  even  when 
this  does  not  give  rise  to  local  trouble,  and  may  not  reveal 
abnormality  on  a  cursory  inspection. 

Another  fruitful  source  is  eye-strain  from  refractive 
error,  when  the  vision  is  closely  applied  to  fine  work  or 
in  reading.  Such  errors  may  go  unnoticed  for  a  time 
when  the  eyes  are  not  so  used  or  while  the  young 
cihary  muscle  is  competent  to  overcome  the  defect,  so 
that  the  difficulty  may  not  assert  itself  till  study  or 
the  requirements  of  application  bring  them  into  pro- 
minence, and  the  compensatory  powers  of  accommodation 
fail. 

Such  sources  of  nerve  irritation  and  exhaustion  are 
quite  competent  to  give  rise  to  neuralgia  and  still  more  to 


Neuralgia  133 

attacks  of  migraine,  but  they  are  more  frequently 
determining  causes  in  the  presence  of  more  general 
failure  of  health  attended  by  anaemia  and  loss  of 
vigour  from  chronic  maladies  or  undue  confinement 
within  doors. 

In  women,  leucorrhcea  and  constipation  are  often 
additional  factors,  and  chronic  poisoning  by  sewer  gas 
should  not  be  overlooked. 

Peripheral  irritation,  unsatisfactory  blood-states,  and 
rheumatic  or  gouty  inflammation  of  the  nerve  sheaths 
and  stroma  constitute  the  chief  factors  in  the  causation 
of  this  painful  malady. 

The  treatment  must  necessarily  correspond,  and 
consists  in  discovering  and  remedying  any  of  the  above- 
mentioned  recognised  causes  of  the  disorder,  while  apply- 
ing those  drugs  which  have  been  found  to  alleviate 
the  pain.  The  most  important  of  these  are  butyl 
chloral,  phenazone,  caffeine,  Cannabis  indica,  gel- 
semium,  quinine,  theobromine,  acetanilid,  pyramidon, 
and  exalgin.  As  many  of  these  are  insoluble,  they 
are  mostly  given  in  cachet  or  tablet,  and  may  advan- 
tageously be  combined.  The  following  are  convenient 
formulae  : 

]^.  Butyl  Chloral  Hydrati        «        »  gv.  iij 

Gelseminini         ....  gr.  -^ 

Glycerini  Tragacanthoa        .         .         .      q.s. 
(To  make  one  pill.) 
Two  such  pills  to  be  taken  at  first,  and  one  hourly  till  six  have  been 
taken  or  the  pain  subsides. 

Antipyrine  or  Phenazone  is  usually  prescribed  alone, 
or  as  a  definite  compound  such  as  Antipyrin  Caffeino- 
citricum  (]\Iigranin)  5  to  15  gr.  or  as  Aceto-pyrine  in  com- 
bination with  acetic  and  salicyHc  acids,  either  in  powder 
or  cachet ;  but  being  soluble  in  water  it  is  often  employed 
in  mixture.  The  following  is  particularly  useful  in 
influenza  and  the  headache  associated  with  it ; 


134  Anti'Neuralgics 

^.  Antipyrin.    .  .  .  "| 

Sod.  Salicyl.  .  .  J-  aa  gr.  x 

Pot.  Bromid.  .  .  J 

Aq.  Cinnamomi  .  .  ,       ad  3  j 

Cannabis  Indica  is  best  given  in  pill,  J  to  f  grain  of 
the  extract  being  administered  alone  or  in  combination 
with  a  similar  quantity  of  the  extract  of  Nux  Vomica. 
It  has  been  employed  in  supra-orbital  neuralgia  and 
in  headache  associated  with  mental  worry  and  sleep- 
lessness. 

Gelsemium  in  5  to  15-minim  doses  of  the  tincture  is 
prescribed  with  Bromide  of  Ammonium  or  Potassium  for 
facial  neuralgia,  especially  in  connection  with  carious 
teeth,  and  may  be  repeated  every  six  hours.  As  above 
stated,  Gelseminine,  the  alkaloid,  is  also  combined  with 
Butyl  Chloral  in  the  proportion  of  2^  grain  to  3  grains 
in  pill  or  tablet. 

Theobromine,  Caffeine,  and  Guaranine  are  closely 
allied  in  constitution  and  therapeutic  effect.  In  addition 
to  their  influence  in  reducing  the  pain  of  neuralgia,  they 
exert  a  stimulant  influence  on  the  heart,  and  it  is  usual 
to  employ  them  on  this  account  in  combination  with 
such  remedies  as  Phenazone,  Acetanilid,  and  Phenacetin. 
They,  however,  belong  to  a  class,  akin  to  xanthin  and 
uric  acid,  known  as  purin  bodies,  which  are  associated 
with  gout,  and  are  productive  of  arterial  tension  and 
sleeplessness,  so  should  be  prescribed  only  in  view  of 
these  limitations. 

The  coal-tar  products  Phenazone,  Pyramidon, 
Phenacetin,  Acetanilid,  and  Exalgin,  with  some  others, 
are  usually  given  in  combination  with  the  preceding.  If 
given  alone  they  are  most  conveniently  taken  as  the 
effervescent  granular  preparations,  in  which  a  suitable 
dose  is  contained  in  one  drachm. 

These  preparations  are,  if  anything,  too  alluring,  and 
in   those    who   are   frequently   liable   to   headache   are 


Anti'Neuralgics  135 

commonly    taken    too    often    and    with    detriment    to 
health. 

One  of  the  best  is  the  combination  of  Phenacetin  and 
Caffeine  Citrate  containing  5  and  2|  grains  respectively 
in  the  drachm. 

These  drugs,  valuable  as  they  are  in  ordinary  neuralgia, 
are  specially  apphcable  to  those  cases  in  which  pain 
is  dependent  on  recognisable  organic  disease,  such  as 
cerebral  or  spinal  tumours,  locomotor  ataxy  and  neuritis 
in  its  various  distribution,  such  as  sciatic,  cervico-brachial, 
musculo-spiral,  and  intercostal.  Where  a  rheumatic 
factor  is  present  the  combinations  with  Salicylic  Acid, 
such  as  Diuretin  (Theobromine  Sahcylate),  Salipyrin, 
(Antipyrin  Salicylate),  and  Salicylate  of  Quinine  or 
Aspirin  (Salicyl  Acetic  acid)  are  specially  suitable. 

Satisfactory  as  one  or  other  of  these  remedies  may 
prove  in  an  actual  attack  of  neuralgia,  none  of  them 
exerts  a  permanent  influence  in  removing  the  disorder  or 
preventing  recurrence.  Furthermore,  in  most  instances 
the  beneficial  effect  is  lessened  with  repetition,  so  that 
larger  doses  have  to  be  employed,  and  such  may  produce 
undesirable  collateral  symptoms  and  exercise  a  harmful 
influence  on  health. 

On  this  account  recourse  must  needs  be  had  to  an 
alternative,  and  this  no  doubt  accounts  for  the  number 
of  such  drugs  which  are  recommended  in  common  affec- 
tions like  neuralgia  and  insomnia. 

It  may  indeed  be  pretty  generally  concluded  that 
when  a  plurality  of  remedies  are  advocated  for  the  same 
complaint,  none  are  really  effective  ;  and  one  might 
even  argue  that  the  curability  of  any  malady  is  in  inverse 
proportion  to  the  number  of  so-called  cures.  Perhaps 
no  disorder  offers  such  a  striking  example  of  this  as 
sciatica,  in  which  remedies  are  so  numerous  and  instance* 
of  speedy  recovery  so  few. 

Jt  is,  therefore,  extremely  undesirable  that  the  treat- 


136  Treatment 

ment  of  neuralgia  should  be  limited  to  the  administra- 
tion of  analgesics,  though  these  are  of  value  in  subduing 
pain  while  more  radical  treatment  is  carried  out. 

For  the  most  part  this  consists  in  eliminating  some 
faulty  state  of  the  system  by  correcting  constipation, 
indigestion,  malarial  taint,  or  local  disease  of  teeth,  nose, 
eyes,  or  ears,  or,  most  common  of  all,  the  blood. 

In  a  very  large  proportion  of  cases  anaemia  and 
debility  are  responsible  for  neuralgia,  particularly  in 
women.  Losses  by  haemorrhage  or  discharges  must  be 
arrested  and  the  waste  made  good  by  ample  diet,  change 
of  air,  and  tonics. 

Many  are  the  emasculated  forms  of  iron  which  have 
been  recommended  and  laboriously  produced,  with  the 
idea  that  they  are  unirritating  or  more  closely  allied  to  the 
organic  combinations  in  which  the  metal  is  disposed  in  the 
organism.  Modern  analysis  and  research  have  done  much 
to  dissipate  the  notion  that  ferruginous  preparations  are 
beneficial  on  account  only  of  being  directly  assimilated. 
More  iron  is  prescribed  in  a  day,  if  not  in  a  dose,  than 
would  be  normally  contained  in  the  entire  body  of  a 
healthy  person  ;  and  it  has  been  shown  not  only  that 
such  large  doses  appear  beneficial  in  chlorosis,  but  that 
most  if  not  all  the  metal  is  recoverable  in  the  fseces, 
indicating  that  apart  from  absorption  the  presence  of 
the  iron  in  the  digestive  tract  effects  some  beneficial 
change,  partly  at  all  events  by  counteracting  other 
chemical  bodies  by  producing  insoluble  combinations. 
This  may  be  the  case  with  ammonium  sulphide  and 
sulphuretted  hydrogen,  since  the  iron  is  disposed  of  as 
sulphide  and  these  compounds  are  capable  of  entering 
into  undesirable  combination  with  haemoglobin. 

The  administration  of  iron  should  be  associated 
with  moderate  purgation,  free  dilution,  and  efficient 
dosage.  It  is  this  which  no  doubt  accounts  for  the 
favourable   effect  of   ferruginous    mineral   waters   when 


Treatment  137 

other  metliods  have  failed,  combined  as  it  usually  is 
with  a  regulated  diet,  open-air  exercise,  and  early 
hours. 

In  the  treatment  of  neuralgia  in  young  anaemic 
women  the  following  formula  will  often  be  found  effectual, 
especially  when  rheumatism  occurs : 


]^.  SodtB  Salicylatis 


Ferri  et  Ammon.  Cit.   .         , 
Sp.  Am.  Aromat.  . 
Aquam  Chloroformi 

Three  times  a  day 


gr.  XX 

gr.  V 

ni  XXX 

adgj 


Recent  experience  has  also  shown  that  the  combina- 
tion of  arsenic  with  iron  is  usually  more  effectual  in 
curing  anaemia  than  either  taken  alone.  The  following 
rather  crude  formula  has  the  merit  of  having  proved  its 
efficiency  in  a  number  of  cases  : 

^.  Tinct.  Ferri  Perchloridi           .        #        .  .  IH,  x 

Liq.  Arsenici  Hydrochlor.       .        .        .  •  ni  v 

Glycerin! .  3ss 

Aquani  destill .  ad  §  j 

Three  times  a  day  after  food. 

The  scale  preparations  of  Citrate  of  Iron  with  Quinine 
or  Strychnine  or  both  are  very  suitable.  Quinine  and 
Iron  may  be  given  in  doses  of  5  to  10  grains,  but  the 
introduction  of  Strychnine  requires  caution  as  to  dose, 
that  of  Strychnine  and  Iron  being  1  to  2  grains  and  that 
of  Quinine,  Strychnine,  and  Iron  2  to  6  grains. 

Sufficient  dilution  is  obtained  by  giving  these  drugs 
directly  after  meals  and  washing  down  the  medicine 
with  a  tumblerful  of  water. 

A  saline  purgative  may  be  added,  but  it  is  usually 
more  convenient  to  order  a  sufficient  quantity  of 
aperient  mineral  water  to  be  taken  the  first  thing  in  the 
morning. 

Bearing    in  minq  the  observation  tha,t  haemoglobin 


138  Diet 

is  broken  up  in  the  day  and  built  up  at  night,  during  the 
period  of  rest,  it  is  an  important  adjuvant  to  the  treatment 
to  enjoin  a  prolonged  period  of  rest,  say  a  night  of  twelve 
hours,  while  this  is  being  carried  out ;  at  the  same  time 
securing  efficient  ventilation  in  the  bedroom  and  a  due 
proportion  of  outdoor  exercise  or  exposure  without  fatigue 
during  the  day. 

The  diet  must  be  adjusted  to  the  digestive  capacity. 
In  many  instances  pain  or  discomfort  after  food  is  a 
prominent  symptom,  and  if  sufficient  nutriment  cannot 
be  comfortably  assimilated,  the  patient  should  be  kept 
in  bed,  or  at  all  events  free  from  fatiguing  exertion,  till 
the  supply  of  food  can  be  raised  to  fairly  normal  pro- 
portion. After  milk  and  eggs,  animal  food  may  be  given 
in  the  form  of  sheep's  brains,  tripe,  sweetbread,  or  calf's 
head,  such  things  being  easier  of  mastication  and 
digestion  than  actual  meat.  Flat  fish,  similarly,  is  more 
suitable  than  other  kinds. 

The  coarser  sorts  of  fish  and  poultry,  unless  boiled 
almost  to  a  pulp,  are  really  less  digestible  than  meat,  and 
it  is  certainly  a  mistake  to  regard  them  as  "  invalid 
diet  "  in  cases  of  gastric  disturbance  or  inefficiency. 

Green  vegetables,  especially  lettuce  and  spinach,  and 
fruit  are  valuable  additions  to  the  meal. 

But  the  main  object  is  to  get  the  patient  on  a  liberal 
and  nutritious  regime  as  speedily  as  possible,  discouraging 
merely  tempting  and  fancy  confections  which  are  no 
substitute  for  food,  though  they  may  be  taken  in  addition 
by  healthy  folk,  perhaps  without  hurt.  As  a  result  of 
bad  teeth  and  defective  appetite  young  women  not 
infrequently  forsake  simple  wholesome  food  in  proper 
quantities  for  what  are  considered  delicacies,  and  a  dietary 
of  tea  and  confectionery  will  often  be  found  a  precursor 
of  the  ultimate  attack. 

The  question  of  change  of  air  constantly  arises  in  these 
cases,  and  when  other    matters  have  been  set  right,  i? 


Occasional  Headaches  139 

generally  beneficial.  Besides  climatic  change,  residence 
away  from  the  usual  surroundings  generally  means 
freedom  from  business  worries  or  harassing  domestic 
affairs  and  makes  for  rest ;  but  precautions  should  be 
taken,  as  far  as  possible,  against  the  indifferent  cooldng 
and  defective  food  arrangements  often  experienced  in 
primitive  country  places  or  at  the  seaside. 

For  the  most  part  in  debilitated,  anasmic  subjects  a 
dry  and  relatively  cool  atmosphere  is  to  be  selected,  such 
as  is  found  on  the  East  Coast  of  England  or  at  an  elevation 
of  some  500  feet.  In  older  people  with  high  arterial 
tension,  a  warm  and  moist  atmosphere,  such  as  that  of  the 
South  and  West  Coasts  and  river  valleys,  is  preferable, 
and  this  also  suits  the  excitable  and  so-called  neurotic 
subjects  best,  but  in  either  case  the  patient  should  not 
go  till  convalescence  is  fairly  established. 

Oeeasional  Headaches  depend  on  a  variety  of 
causes,  vary  greatly  in  character  and  intensity,  are  more 
diffuse  or  difficult  to  localise,  and  do  not,  so  far  as  we  can 
determine,  involve  any  particular  structure — that  is,  are 
not  traceable  to  the  area  of  distribution  of  any  special 
nerve  or  artery  as  in  the  previous  group.  They  have 
more  the  character  of  what  have  been  termed  "  massive 
pains  "  and  are  not  usually  to  be  compared  in  acuteness 
with  those  in  either  of  the  preceding  groups. 

For  the  most  part  "  occasional "  headaches  are 
not  associated  with  serious  organic  disease,  they  occur 
at  long  intervals,  are  of  brief  duration,  constituting  the 
minor  ailments  of  otherwise  healthy  people,  and  so  come 
more  particularly  into  the  domain  of  minor  medicine. 

The  presence  of  deleterious  substances  in  the  blood 
as  a  result  of  disturbed  functions  would  appear  to  be  the 
commonest  factor,  though  this  may  have  a  direct  in- 
fluence in  producing  altered  distribution  of  blood  by 
disturbing  heart  action  or  altering  peripheral  resistance, 
locally  or  generally.     It  is  certainly  noticeable  that  such 


140  Occasional  Headaches 

headaches  are  associated  with  flushing  or  pallor  of  the 
face,  alteration  of  the  complexion  and  suffusion  of  the 
eyes  with  either  fulness  or  depression  around  them,  and 
change  from  the  normal  size  of  the  pupil.  The  lids  look 
heavy,  and  altogether  there  is  an  altered  appearance  in 
the  face  that  does  not  escape  an  observant  person  who 
is  familiar  with  the  patient.  The  commonest  source  of 
such  toxins  is  the  digestive  tract,  especially  indigestion, 
constipation,  and  interference  with  the  action  of  the 
liver. 

These  disturbances  have  already  been  sufficiently 
dealt  with  in  a  preceding  chapter,  and  there  is  no  need 
to  consider  them  further  here  except  to  suggest  in  per- 
sistent cases  such  remedies  as  the  effervescing  citrate  of 
magnesia,  artificial  Carlsbad  Salts  (Kutnow's  Powder), 
or  a  mixture  containing  laxative  and  stomachic  drugs 
such  as  the  following  : 

^.  Succi  TaraxFici  .         ,         .        .         .        .        .      5s3 
Sodii  Sulphatis  .         .         .         .         .         .         .       5  ss 

T.  Nucis  Vomicse vi  v 

Sp.  Am.  Arom tti  xx 

Aquam  Chloroformi ad  5  j 

Three  times  a  day  before  food. 

Taraxacum  is  not  officially  regarded  as  a  potent 
remedy,  but  the  above  combination  has  proved  of  service 
in  many  cases. 

What  may  be  termed  "  toxic  headache  "  results  from 
the  action  of  poisons  introduced  from  without  or  generated 
in  the  body  often  complicated  by  secondary  effects  such 
as  direct  irritation  of  nerves  or  contraction  of  blood-vessels, 
which  are  very  difficult  to  distinguish. 

Poisons  from  without  which  are  productive  of  head- 
ache include  carbon  dioxide,  carbonic  oxide,  and  acety- 
lene derived  from  deficient  ventilation,  overcrowding,  and 
the  combustion  of  coke  or  gas  in  stoves  with  defective 
draught,  or  in  the  latter  case  which  "  light  back,"     The 


Remedies  1 4  ^ 

inhalation  of  fumes  in  a  chemical  laboratory,  in  some 
manufacturing  processes,  or  from  defective  drains  may 
produce  headache  in  a  few  minutes  which  may  last  a 
considerable  time.  Perhaps  the  only  remedy  is  a  sojourn 
in  fresh  air,  but  such  experience  should  be  avoided  or 
the  circumstances  corrected.  Toxic  headache  is  also 
produced  by  alcohol  and  lead. 

The  autogenetic  poisons,  apart  from  those  associated 
with  recognisable  digestive  disturbances  and  constipation, 
are  derived  from  faulty  or  excessive  metabolism,  being 
in  most  cases  due  either  to  excessive  production  or 
defective  ehmination  ;  such  are  the  causes  of  headache 
in  fatigue,  in  fever,  and  in  gout. 

In  fever,  headache  is  best  relieved  by  reducing  the 
temperature  and  giving  fluids  ;  one  of  the  most  striking 
features  of  cold  bathing  for  typhoid  fever  when  in  vogue 
was  the  subsidence  of  this  symptom. 

Cold  applications  to  the  head  are  still  employed, 
either  as  some  form  of  ice-cap  or  as  evaporating  lotion, 
but  the  most  comfortable  and  effective  arrangement  is 
the  ordinary  rubber  water-bottle,  filled  with  cold  water 
or  shaved  ice  and  placed  under  the  nape  of  the  neck, 
wrapped  in  a  smooth  towel. 

Most  of  the  antipyretic  drugs  exert  a  definite  influence 
on  headache,  and  this  is  true  not  only  of  the  coal-tar 
products,  but  also  of  such  diaphoretics  as  acetate  of 
ammonia  and  nitrous  ether. 

Fatigue  headache  is  a  common  experience  of  over- 
exertion, whether  physical  or  mental;  less  familiar  per- 
haps, as  a  recognised  cause,  is  the  over-use  of  the  special 
senses,  but  excessive  stimulation  of  the  eyes,  of  the  ears, 
and  sense  of  smell  are  certainly  productive  of  fatigue 
associated  with  headache,  which  appears  to  be  seated, 
so  far  as  it  can  be  localised,  in  the  forehead.  The  sense 
of  fatigue  is  often  closely  bound  up  with  want  of  food, 
and  the  headaches  so  common  in  visitors  to  large  cities 


142  Remedies 

are  usually  the  result  of  this  complex  causation  and  are 
generally  to  be  remedied  by  rest  and  food  with  nerve 
stimulants  such  as  tea,  coffee,  or  alcohol. 

The  headache  from  active  study  often  associated 
with  cold  feet,  and  perhaps  produced  largely  by  stooping 
over  a  book  in  a  close  atmosphere,  calls  for  exercise  and 
fresh  air,  and  is  best  remedied  by  a  short  brisk  walk. 
This  is  a  common  experience  in  student  life.  Perhaps  the 
best  remedy  for  such  headaches  in  modern  times  has  been 
the  bicycle. 

Chloride  of  ammonium  has  frequently  proved  of 
great  value  in  various  forms  of  headache,  when  given  in 
adequate  doses  (10  to  30  grains). 

For  headache  in  gouty  subjects  which  is  liable  to 
be  persistent  and  recurring,  and  usually  associated  with 
high  arterial  tension,  iodide  of  potassium  appears  the 
most  reliable  drug.  It  should  be  given  in  moderately 
large  doses,  10  grains  being  generally  sufiicient,  but 
it  must  be  continued  regularly  for  some  days,  and  ac- 
companied by  saline  purgatives  and  a  reduced  amount 
of  animal  food. 

Some  individuals  are  prone  to  headache  from  climatic 
conditions,  whether  due  to  variation  in  the  direction  of 
the  wind  or  to  change  of  locahty — such  headache  is 
either  referred  to  a  cold  dry  air,  described  as  bracmg,  or 
to  the  opposite  state  of  moist  warmth,  known  as  relaxing. 
The  first  may  be  met  by  a  combination  of  Iodide  and 
Bromide  of  Potassium  or  by  a  mixture  containing  Potas- 
sium Citrate,  Acetate  of  Ammonium,  and  Nitrous 
Ether  ;  whUe  the  other  is  in  a  measure  counteracted  by 
Nux  Vomica  combined  with  Quinine  and  Ammonia. 

Unless,  however,  headache  is  really  severe  and  per- 
sistent, it  is  scarcely  necessary  to  have  recourse  to  drug?, 
since  the  symptom  subsides  after  a  while  as  the  system 
becomes  adjusted  to  the  altered  conditions. 

Wind   and   fog   also   induce  headache   in   many   in- 


Sea-Sickness  i43 

dividuals,  but  scarcely  to  the  extent  of  requiring  medica- 
tion, even  if  such  could  be  beneficially  applied,  and  the 
same  may  be  said  of  headache  following  prolonged  cold 
bathing,  since  this  usually  subsides  as  the  surface  tem- 
perature is  restored. 

Sea-Siekness. — Nausea  withdepression,  amounting 
in  severe  cases  to  collapse,  and  actual  vomiting  is  only 
too  well  known  as  an  accompaniment  of  sea  voyages. 
The  disturbance  is  commonly  associated  with  the  un- 
accustomed movement  and  may  affect  those  who  are 
susceptible  in  a  train  journey,  while  swinging,  even  in 
a  rowing-boat  on  still  water,  or  under  the  influence  of 
any  varied  and  unusual  motion,  such  even  as  riding  in 
a  carriage  ;  and  the  motion  of  a  camel,  which  has  a 
peculiar  side-to-side  gait,  is  especially  obnoxious  in  this 
respect  to  novices. 

The  causation  of  the  malady  is  not  so  obscure  as  com- 
plex. Many  persons  on  commencing  a  descent,  as  in  a 
lift,  are  conscious  of  a  peculiar  sensation  of  sinking  in 
the  epigastric  region,  which  when  frequently  repeated, 
as  in  the  pitching  of  a  vessel,  appears  to  induce  nausea 
culminating  in  vomiting — besides  this,  the  confused 
visual  sensations  due  to  the  complex  motion  of  a  boat 
pitching  and  rolling,  and  the  effect  of  these  movements 
on  the  semi-circular  canals,  induce  giddiness  and  vertigo 
through  their  repeated  and  alternating  impressions  on 
the  equilibrium  centres  in  the  cerebellum  and  corpora 
quadrigemina,  adding  headache  and  collapse  attended 
with  faintness  and  chilliness,  so  that  a  condition  ul- 
timately results  similar  to  that  of  concussion  of  the 
brain  or  nervous  shock. 

The  patient  becomes  pale  with  clammy  cold  skin 
and  suffers  from  deadly  nausea,  vomiting  of  reflex  char- 
acter with  voiding  of  the  contents  of  the  stomach  and 
duodenum  and  sometimes  diarrhoea.  Attacks  of  hemi- 
crania  often  occur  in  those  who  are  subject  to  it,  and 


1 44  Sea^SicknesS 

complete  nervous  prostration  with  muscular  relaxation 
ensues,  sometimes  with  loss  of  consciousness,  so  that 
the  similarity  to  the  effects  of  a  blow  on  the  head  is 
very  close. 

People  are  not  all  affected  in  this  way,  though  cer- 
tainly the  majority  suffer  to  some  degree.  A  few  for- 
tunate individuals  even  of  a  highly  developed  nervous 
type  do  not  know  what  sea-sickness  means,  others  suffer 
only  slightly  or  for  a  brief  period  and  perhaps  not  on 
every  voyage,  the  disturbance  depending  on  the  state 
of  health  or  the  degree  of  movement. 

Custom  has  an  educating  effect  and  the  symptoms 
diminish  with  use,  but  this  is  not  always  the  case,  and 
even  some  seamen  suffer  at  the  commencement  of  each 
voyage  ;  and  in  continuous  rough  weather,  though  actual 
vomiting  does  not  afflict  a  hardened  crew,  there  is  a 
disturbance  of  appetite,  temper,  and  equanimity  which 
is  attributable  to  the  persistent  turmoil. 

In  recent  times  the  increase  in  size  of  ocean-going 
steamers  has  greatly  improved  their  steadiness,  and 
the  frequency  of  sea-sickness  has  correspondingly  di- 
minished, so  that  we  no  longer  hear,  as  formerly,  of  per- 
sistently sea-sick  persons  being  put  ashore  on  the  voyage 
to  the  East,  as  the  only  means  of  preserving  life. 

The  most  constant  scene  of  the  malady  now  is  pro- 
bably the  Channel  crossing,  where  the  boats  are  relatively 
small,  the  sea  choppy,  and  the  travellers  inexperienced. 
It  may  be  also  that  Continental  people,  who  form  a  large 
proportion  of  the  passengers,  are  more  susceptible  than 
ourselves,  but  whatever  the  cause  there  is  certainly  no 
lack  of  sea-sick  folk  on  these  short  journeys. 

Many  people  appreciate  on  going  on  board  that  all 
their  senses  are  assailed  at  once.  The  rattle  and  din 
of  machinery,  the  waving  spars,  apparently  rising  and 
falhng  horizon,  and  the  close  atmosphere  of  the  saloon 
laden  with  odours  of  cooking  and  machine  oil,  to  which 


Sea^Sickness  145 

are  soon  added  the  sight  and  sound  of  those  who  are 
already  overcome,  added  to  previous  apprehension  and 
often  an  empty  stomach,  render  them  speedy  victims. 
and  once  estabhshed  the  symptoms  are  certain  to  con- 
tinue and  increase  during  the  continuance  of  the  brief 
voyage. 

In  most  instances  the  attack  passes  off  in  the  course 
of  two  or  three  days  even  on  a  long  voyage  unless  bad 
weather  is  encountered,  and  there  are  those  who  aver 
that  it  is  worth  while  to  go  through  the  preliminary 
discomforts  for  the  sake  of  the  renewed  health  and 
vigour  that  usually  succeed.  On  the  other  hand,  those 
who  land  after  an  incomplete  experience  commonly 
suffer  from  gastro-intestinal  derangement  with  headache, 
vertigo,  and  malaise  for  some  days  ;  so  that  any  treat- 
ment that  can  be  adopted  is  best  directed  to  entire 
prevention,  or  such  mitigation  of  the  symptoms  as 
circumstances  permit. 

The  remedy  which  has  been  hitherto  most  popular 
is  bromide  of  potassium,  though  the  corresponding 
salts  of  ammonium  or  sodium  might  be  even  better,  and 
a  combination  of  the  three  best  of  all.  The  important 
conditions  are  that  a  full  dose  (5  j )  should  be  taken 
sufhciently  diluted  in  half  a  pint  of  mineral  water  about 
an  hour  or  at  least  haff  an  hour  before  commencing 
the  voyage,  so  as  to  give  time  for  absorption  before  this 
necessary  function  is  disturbed.  The  patient  should  lie 
down,  selecting  a  position  as  near  the  centre  of  the  vessel 
as  possible,  keeping  the  head  low  and  taking  precautions 
against  cold,  especially  if  remaining  on  deck,  as  is  gener- 
ally advisable,  and  it  is  better  to  lie  lengthways  rather 
than  across  the  vessel  since  the  lateral  motion  is  commonly 
the  more  extensive,  and  rolling  from  side  to  side  is  less 
upsetting  than  the  alternate  tipping  up  of  the  head 
and  feet.  Moderate  pressure  on  the  abdomen  by  a  pad 
and  firm  bandage  is  a  comfort  to  some.     A  full  meal 

10 


H^  A  Specific 

should  be  taken  two  hours  before  starting,  as  the  stomach 
is  less  impressionable  in  mid-digestion. 

Many  who  feel  uncomfortable  during  a  short  voyage 
are  really  suffering  from  fatigue  and  lack  of  food  imposed 
by  restlessness  and  the  apprehension  of  being  ill,  and  not 
from  mal-de-mer  at  all. 

In  any  case  retching  is  more  likely  to  occur  and  is 
more  distressing  with  an  empty  stomach,  and  the  at- 
tempt to  make  the  deficiency  good  while  on  the  vo^^^age 
is  a  doubtful  experiment. 

A  more  modern  and  still  more  efficient  preventive 
is  chloretone.  This  camphor-like  substance,  triclilor- 
tertiary-butyl  alcohol,  is  nearly  insoluble  in  water  and 
volatilises  easily  at  comparatively  low  temperatures. 
It  should  therefore  be  kept  in  a  stoppered  bottle,  or, 
if  made  up  in  powders,  should  be  enclosed  in  paraffin 
paper,  but  is  most  conveniently  taken  in  gelatine  cachets  ; 
5  grains  is  usually  a  sufficient  dose,  the  sedative  effects 
lasting  five  or  six  hours.  Ample  experience  of  its  value 
has  already  been  obtained  not  only  in  single  doses  for 
short  voyages,  but  when  repeated  twice  a  day  for  longer 
voyages,  and  it  may  be  considered  quite  reliable. 

The  ultimate  remedy  to  fall  back  upon  in  obstinate 
and  protracted  cases  is  morphine,  which  has  the  advantage 
of  being  administered  subcutaneously  and  so  acts  in 
spite  of  vomiting.  A  quarter  of  a  grain  is  usually  suffi- 
cient, and  as  it  may  need  repetition  the  dose  is  best  kept 
within  small  limits. 

For  the  general  regimen  in  those  who  suffer  in  spite, 
or  in  the  absence,  of  remedies ;  recumbency,  fresh  air, 
and  abstention  from  food  must  be  adhered  to ;  cold 
drinks  such  as  lemon  juice  with  effervescing  mineral  water, 
whisky  or  brandy  with  aerated  water,  and  later  diluted 
milk  or  perhaps  bottled  stout  or  ale  with  a  few  biscuits, 
can  be  taken  ;  but  for  the  most  part  it  is  as  well  to  take 
nothing  but  water  to  wash  out  the  stomach  and  ease  the 


Palliatives  147 

vomiting  until  recovery  ensues  spontaneously,  as  it 
usually  does  in  twenty-four  to  forty-eight  hours. 

If  the  voyage  lasts  a  week  or  longer,  the  restored 
health  and  appetite  speedily  make  amends  for  the  wastage 
of  the  first  days. 

Curiously  enough,  invalids  and  convalescents,  who 
form  a  considerable  proportion  of  those  crossing  the 
Channel  on  the  way  to  health  resorts,  suffer  less  in  this 
respect  than  many  in  robust  health,  so  the  dread  of  sea- 
sickness, especially  with  the  aid  of  chloretone,  need  be 
no  deterrent  in  such  cases. 

It  might  be  added  that  in  this  as  in  most  other  phy- 
siological disturbances  the  young  commonly  get  over 
their  discomfort  more  quickly  than  those  in  a  later  period 
of  life,  in  whom  the  general  disturbance  is  more  profound, 
and  there  have  been  instances  in  which  the  headache, 
vertigo,  and  nausea  have  persisted  for  days  or  weeks 
after  landing  and  have  been  the  forerunners  of  serious 
lesions  of  the  cerebral  vessels  resulting  in  apoplexy  and 
hemiplegia,  in  those  suffering  from  degeneration  of  the 
cerebral  arteries. 


CHAPTER   V 
THE  CIRCULATORY  SYSTEM 

It  is  a  pretty  constant  experience  in  practice  that 
patients  complain  of  weakness  and  of  being  readily 
fatigued,  without  mentioning  anything  more  definite, 
or  alluding  to  any  local  distress.  Examination  often 
fails  to  discover  any  organic  lesion  adequate  to  explain 
the  loss  of  vigour.  There  are,  however,  certain  obscure 
complaints  to  which  such  symptoms  may  be  assignable 
and  which  should  be  considered  before  concluding  that 
the  condition  is  functional. 

Chief  among  these  are  diseases  of  the  heart  and 
kidneys.  Long  before  dropsy  develops,  or  any  other  sign 
which  attracts  attention  to  either  of  these  organs,  a  con- 
sciousness of  failing  power  and  of  inability  to  perform 
ordinary  avocations,  or  of  greater  effort  in  doing  so, 
impresses  itself  on  the  patient's  mind. 

Every  now  and  then  careful  examination  of  the  urine 
will  reveal  the  presence  of  albumen,  pus,  or  tube-casts, 
or  perhaps  only  a  constant  deficit  in  the  output  of  solids, 
so  that  there  is  persistent  low  specific  gravity. 

La  connection  with  the  heart,  apart  from  definite 
valvular  mischief,  which  however  may  first  be  recognised, 
especially  in  elderly  people,  in  consequence  of  complaint 
of  languor  leading  to  examination,  there  may  be  found 
weakness  of  the  heart's  action  from  defective  contractility 
associated  with  myocardial  disease  or  degeneration, 
which  is  a  very  obscure  matter,  sometimes  dependent  on 
alcoholism  or  syphilis  which  may  not  be  avowed. 

Such  myocardial  disease  may  not  give  rise  to  any 

148 


Obscure  Organic  Diseases  149 

obtrusive  murraur,  but  the  weakness  of  the  heart  sounds 
and  impulse  with  some  displacement  of  the  apex  beat 
may  be  all  that  can  be  discovered.  Sometimes  there  is  a 
mitral  systolic  murmur  from  dilatation  associated  with  a 
flipping  first  sound,  and  occasional  irregularity  of  a 
weak,  pulse.  Further  evidence  may  be  found  in  con- 
gestion and  oedema  of  the  bases  of  the  lungs,  and  closer 
questioning  may  elicit  a  confession  of  sensations  of 
faintness,  palpitation  and  muscular  cramps,  or  of  vertigo 
on  rising  and  loss  of  breath  on  slight  exertion.  These 
indications  in  a  patient  past  middle  life  may  be  the 
precursors  of  acute  cardiac  failure  or  of  a  cerebral  attack 
from  embolism,  thrombosis,  or  haemorrhage. 

It  may  be  assumed  that  aneurysm  of  the  arch  of 
the  aorta  in  any  part  would  reveal  itself  comparatively 
early,  but  there  is  one  region — namely,  the  descending 
thoracic  aorta — in  which  such  disease  has  been  hitherto 
almost  invariably  overlooked.  Rarely  reaching  the 
surface,  and  not  interfering  greatly  with  any  important 
organ,  such  aneurysms  often  attain  the  size  of  a  cocoa- 
nut  or  larger  without  attracting  attention ;  the  only 
indications  being  pain  referred  to  the  left  side  of  the 
thorax,  varying  in  intensity  and  often  more  noticeable 
at  night ;  this  feeling  of  fatigue  and  want  of  energy 
being  associated  with  low  arterial  tension. 

There  must  be  in  every  one's  experience  instances  in 
which  a  sudden  profuse  and  fatal  hsemoptysis  has  been  the 
first,  last,  and  only  recognised  indication  of  this  disease, 
and  whatever  may  be  the  opinion  as  regards  the  cura- 
bility of  this  disorder  and  the  wisdom  of  allowing  the 
patient  for  his  own  peace  of  mind  to  remain  in  ignor- 
ance of  it  as  long  as  possible ;  no  medical  man  would 
feel  easy  should  such  an  accident  occur  to  one  of  his 
patients  whom  he  had  recently  passed  as  sound,  or  would 
forgo  the  manifest  advantages  of  correct  prognosis  as 
affecting  his  patient's  affairs  and  his  own  credit. 


1 50  Debility 

When  any  suspicion  of  the  kind  arises,  practical 
certainty  can  be  attained  by  the  use  of  the  X-rays  either 
by  a  radiogram  or  the  use  of  the  screen. 

Other  obscure  causes  of  general  weakness  are  diabetes 
and  Addison's  disease,  the  manifestations  of  which  are 
familiar  enough,  but  it  is  important  to  bear  them  in  mind 
in  this  connection,  since  patients  more  often  complain 
of  weakness  and  fatigue  than  of  the  more  characteristic 
features  of  these  disorders,  and  these  may  only  appear 
at  a  later  stage  and  require  special  investigation. 

In  all  cases  then  in  which  weakness,  languor,  and 
fatigue  are  complained  of,  these  obscure  diseases,  for  the 
most  part  productive  of  low  blood-pressure,  should  be 
borne  in  mind,  particularly  when  they  are  persistent 
and  perhaps  associated  with  actual  loss  of  weight. 

Having  excluded  these  obscure  and  somewhat  rare 
organic  diseases,  there  still  remains  a  very  large  residue 
of  cases  in  which  weakness  and  fatigue  are  persistently 
complained  of,  and  which  are  usually  regarded  either 
as  cases  of  "  anaemia  and  debility  "  or  else  as  neuroses. 
The  subjects  of  ansemia  and  debility  exhibit  de- 
partures from  the  normal  standard  of  health  rather  on 
the  negative  side,  such  as  defective  nervous  and  muscular 
power,  loss  of  appetite,  unsatisfactory  digestion,  and  con- 
stipation associated  with  some  pallor  and  possibly  lessened 
force  of  the  heart's  action  ;  resembling  in  many  respects 
the  features  of  convalescence  from  acute  disease  but 
without  any  such  history. 

Instances  of  this  kind  occur  at  all  periods  of  life 
from  childhood  to  old  age,  and  appear  to  be  associated 
mainly  with  indoor  and  town  life  and  a  deficiency  of 
sunlight,  fresh  air,  and  healthy  exercise.  The  best 
remedy,  as  in  the  case  of  convalescents,  is  a  change  to 
the  country  or  seaside,  preferably  where  the  air  is 
bracing — that  is,  cool  and  dry. 

Prugs  are  of  secondary  importance,  but  where  circum- 


Neurosis  151 

stances  do  not  permit  of  change  of  air,  a  bitter  stomachic 
with  ammonia  or  mineral  acid,  the  combination  of  iron, 
arsenic  and  strychnine,  or  such  a  preparation  as  Easton's 
s;/rup,  is  usually  prescribed,  with  such  emendations  in 
the  matter  of  food,  rest,  recreation,  etc.,  as  the  circum- 
stances permit,  for  it  must  be  admitted  that  "  res  angusta 
domi  "  have  often  much  to  do  with  this  condition. 

The  cases  of  neuposis,  in  which  fatigue  and  weakness 
are  the  main  complaint,  are  generally  recognisable  both 
by  their  persistence  and  their  peculiar  psychical  features. 
They  are  characterised  by  introspection  and  the  tendency 
to  pay  as  much  or  more  attention  to  subjective  sensations 
as  to  objective  impressions.  They  can  always  be  relied 
on  to  undertake  the  handling  of  their  own  case  with 
conspicuous  lack  of  success,  but  their  assumed  better 
knowledge,  objections  to  the  remedies  advised  and  fore- 
casts of  failure,  are  serious  stumbling-blocks  to  the 
practitioner,  unless  he  is  one  of  those  who  can  subordinate 
rational  therapeutics  to  the  arts  of  the  psychological 
conjurer.  For  the  most  part  the  bromides  and  valerian 
have  chiefly  proved  of  service,  outside  the  special  cures 
advocated  in  such  cases,  but  the  subject  has  been  fully 
dealt  with  in  Goodhart's  Common  Neuroses. 

Perhaps  there  is  no  expression  so  frequently  employed 
in  regard  to  a  somewhat  vague  condition  of  ill-health  as 
that  of  being  "pun  down."  The  phrase  appears  to 
cover  a  condition  of  asthenia  which  is  unassociated  with 
definite  physical  signs  of  disease  in  any  particular  organ 
or  system.  The  term  has  no  doubt  taken  its  origin  from 
analogy  with  the  feeble  action  of  clockwork  at  the  end 
of  its  spring,  and  connotes  a  general  reduction  of  activity 
of  most  of  the  bodily  functions,  though  the  most  prominent 
features  may  be  associated  with  the  nervous  system. 
The  daily  life  of  most  people  involves  the  performance  of 
duties  which  are  not  associated  with  immediate  pleasure 
or  profit,  and  even  where  these  are  involved  there  may 


152  On  being  ^*Run  Down^' 

be  an  output  of  energy  which  is  not  always  adequately 
balanced  by  corresponding  rest  and  nutrition.  This 
results  in  the  exhaustion  of  a  latent  store  of  energy  and 
energy-supplying  material,  together  with  an  accumulation 
of  effete  matters  which  tend  to  silt  up  the  machine.  The 
functions  of  nutrition  and  elimination  fail  at  times  as  the 
result  of  over-action  or  want  of  sufficient  stimulus  in 
motive  or  occupation.  Such  may  be  the  result  of  con- 
tinuous monotonous  drudgery,  or  special  application 
which  has  interfered  with  the  reasonable  distribution 
of  the  energies  in  other  directions.  It  is  commonly  met 
with  in  those  who  have  been  in  attendance  on  sick  rela- 
tives, where  constant  watching  is  associated  with  keen 
anxiety  and  the  exercise  of  continuous  self-control, 
or  may  result  from  the  undue  expenditure  of  nervous 
energy  associated  with  too  active  social  life,  much  excite- 
ment, and  insufficient  rest.  The  condition  of  being  "  run 
down  "  shows  itself  in  failing  energy,  loss  of  appetite, 
and  deficient  action  of  the  various  secretory  organs. 
The  complexion  becomes  pale  and  clouded,  there  is  a 
want  of  animation,  and  often  actual  mental  depression, 
the  organism  ceasing  to  re-act  satisfactorily  to  accus- 
tomed stimuli.  Desire  fails,  and  often  the  sufferer  is 
so  enthralled  in  worries  and  anxieties  that  it  appears 
impossible  for  him  to  free  his  mind  of  them,  depute  his 
affairs  or  suspend  his  attention  even  for  a  time. 

The  chief  remedy  for  this  state  of  things  is  entire 
change  of  occupation  and  surroundings.  For  a  few  days 
at  least  the  individual  must  shake  off  the  routine  which 
has  consumed  his  energies  in  one  particular  channel. 
Not  merely  rest  is  required,  but  rest  in  association  with 
such  enjoyment  as  may  be  within  reach,  and  in  most 
instances  in  an  atmosphere  different  from  that  in  which 
the  patient  usually  lives.  Relaxation  for  a  time  from 
the  strain  of  watching,  from  the  monotony  of  simple 
duties,  from  the  contemplation  of  matters  incapable  of 


Remedies  153 

satisfactory  solution,  and  from  uphill  work  in  general, 
are  essential  for  the  mind  to  recover  its  elasticity,  so  as 
to  regard  affairs  in  a  proper  light,  to  restore  the  sense  of 
proportion,  and  to  re-awaken  the  energies  which  are  in 
abeyance.  Atmospheric  conditions  may  have  some  share 
in  the  development  of  this  state,  and  it  more  commonly 
occurs  in  the  spring  or  late  winter,  when  warm  weather 
succeeds  to  cold,  after  a  prolonged  imprisonment  within 
doors,  and  perhaps  a  greater  lack  of  variety  of  life  than 
is  possible  under  more  favourable  climatic  conditions. 
The  alteration  of  health  is  not  limited  to  mental  disturb- 
ance, but  shows  itself  in  lowered  arterial  tension,  dilated 
pupils,  loss  of  muscular  tone,  and  deficient  force  of  the 
heart  beat,  with  some  loss  of  fat  and  often  a  tendency  to 
lymph  stasis  and  loss  of  elasticity  in  the  skin,  manifested 
by  fiabbiness  of  the  tissues,  especially  noticeable  in  the  face. 
It  is  generally  believed  that  in  addition  to  what  has 
already  been  mentioned  there  is  a  further  constitutional 
weakness  leading  to  a  greater  tendency  either  to  contract 
contagious  disorders  or  to  develop  others  to  which  the 
patient  may  be  subject  or  exposed. 

The  absence  of  efficiency  in  work  and  loss  of  power 
of  enjoyment,  with  disturbance  of  the  usual  mental 
characteristics,  together  with  the  tendency  to  develop 
or  acquire  definite  maladies,  render  it  important  to  restore 
the  proper  state  of  health  without  delay.  As  has  already 
been  suggested,  the  most  effective  remedy  is  a  complete 
change  of  locality  and  occupation.  Some  new  interest 
should  be  encouraged  for  a  time,  and  if  the  patient  can 
healthily  indulge  in  a  favourite  hobby,  so  much  the 
better.  In  the  absence  of  this,  residence  with  friends  or 
in  an  hotel  or  hydropathic  establishment  would  be  useful, 
unless  the  patient  is  really  unable  to  free  himself  from 
the  daily  routine  ;  in  which  case  some  definite  change 
must  be  effected  in  favour  of  relaxation,  exercise  in  the 
open  air,  change  of  diet,  and  early  hours.     In  regard 


154  The  Rest  Cure 

to  drugs  the  most  useful  are  mineral  acids  and  combina- 
tions of  strj^chnine,  quinine,  or  other  preparations  of 
cinchona.  Some  stimulant  may  be  needed,  and  at  first 
mild  mercurial  purgatives  followed  by  salines. 

Extreme  cases  of  this  kind,  particularly  in  women, 
are  constantly  treated  by  a  modification  of  the  Weir 
jMitchell  system  which  has  been  termed  the  "  rest  cure." 
The  principle  is  the  "  conservation  of  energy  "  by  keeping 
the  patient  in  bed  while  feeding  generously.  A  most 
important  feature,  however,  is  removal  from  the  ordinary 
environment  and  the  substitution  of  such  quiet  interests 
and  companionship  as  may  keep  the  patient's  mind  away 
from  habitual  worries. 

Those  only  who  are  confidants  in  the  daily  life  of 
men  and  women  know  the  harassing  strain  constantly 
put,  more  especially  on  the  latter,  in  endeavouring  to 
maintain  uniformity  of  behaviour  and  demeanour  under 
difficult  circumstances — trying  to  keep  one's  temper  and 
some  one  else's  as  well,  suppressing  natural  inchnations 
out  of  consideration  for  others'  interests,  and  pulhng 
generally  against  the  stream.  These  things  produce  a 
civil  war  of  emotions  which  leads  to  nervous  exhaustion 
and  can  only  be  remedied  by  seclusion  of  the  patient 
and  exclusion  of  relatives  and  friends  for  a  time,  under 
judicious  professional  advice. 

A  small  proportion  of  cases  only  call  for  such  a  re- 
latively severe  measure,  and  only  a  minority  could  afford 
the   usual    expense  in  a    special    establishment. 

Variation  in  the  Tension  and  Distribution 
of  Blood  in  the  general  circulation  is  liable  to  produce 
minor  discomforts  when  the  general  tone  of  the  system  is 
relaxed.  Such  sensations  as  "  pins  and  needles  "  in  the  ex- 
tremities, or  numbness  from  relatively  slight  pressure,  are 
prone  to  occur  with  very  much  greater  frequency  at  such 
times  than  at  others.  This  would  appear  to  be  due  to  loss 
of  tone  in  the  muscles  associated  with  deficient  arterial 


Syncope  155 

tension.  Under  healthy  conditions  the  general  sustained 
muscular  contraction  tends  to  hold  open  not  only  the 
local  vessels  but  to  protect  from  pressure  the  main  trunks 
lying  between  and  beneath  the  muscles.  When  this  is 
relaxed,  these,  hke  pads  of  wet  clay,  offer  no  support, 
but  tend  rather,  under  the  weight  of  the  body,  to  oblite- 
rate the  lumen  of  these  trunks.  This  results  in  diminu- 
tion of  the  circulation  not  only  in  the  distal  part  of  the 
limb,  but  especially  in  the  nerve  trunks  themselves. 
The  aching  tenderness  which  follows  change  of  position 
is  an  indication  of  the  restoration  of  circulation  to  the 
antemic  parts.  It  may  be  noted  that  the  effects  of 
alcohol  have  a  strong  tendency  in  this  same  direction, 
and  the  worst  cases  of  so-called  "  pressure  paralysis  " 
result  from  the  deep  sleep  and  relaxed  arterial  and  mus- 
cular tension  associated  with  excess  of  alcohol,  and  have 
been  sometimes  spoken  of  as  "  Saturday  night  paralysis." 
The  recurrence  of  these  minor  discomforts  in  the  general 
circulation  indicates  the  desirability  of  taking  such 
cardiac  and  general  tonics  as  strychnine  or  quinine. 

Syneope. — Sudden  loss  of  consciousness,  associated 
with  failure  of  the  circulation,  not  involving  serious 
organic  disease,  is  frequently  met  with  in  young  adults 
of  both  sexes.  The  most  common  exciting  cause  is 
emotional  excitement,  often  associated  with  extremes  of 
heat  or  cold,  or  impure  atmosphere.  It  may  also  result 
from  sudden  attacks  of  acute  pain,  or  from  the  lack  of 
food.  On  this  account  it  is  particularly  liable  to  occur 
in  the  early  morning  when  any  demand  is  made  on  the 
energies  before  breakfast,  more  particularly  within  doors. 
The  preMminary  sensations  are  usually  tingling  in  the 
extremities,  a  feeling  of  giddiness  and  coldness,  a  slight 
clammy  perspiration,  and  a  gradual  failing  of  the  senses 
marked  by  apparent  remoteness  of  sights  and  sounds, 
until  consciousness  is  entirely  lost.  Complete  relaxation 
of  the  muscles  occurs,  so  that  the  patient  subsides  in  a 


156  Syncope 

heap,  contrasting  with  epilepsy,  in  which  the  muscles  are 
rigid  and  the  patient  falls  more  violently.  The  appear- 
ance of  a  person  about  to  faint  is  characteristic.  He 
becomes  rapidly  pale,  has  a  vacant  expression,  the  lids 
fall  over  the  eyes,  and  the  hands  become  flaccid  and  the 
grasp  uncertain.  In  syncope  of  this  description  the 
attack  is  rarely  so  absolutely  sudden  but  that  the  patient 
can  lean  on  or  seize  some  neighbouring  object,  and  actual 
injury  rarely  occurs,  unless  there  is  proximity  to  some 
dangerous  object,  such  as  a  fire,  or  declivity.  In  many 
cases,  on  feeling  these  indications,  the  patient  attempts 
to  reach  the  open  air,  and  the  effort  of  doing  so,  and 
assuming  a  vertical  attitude,  precipitates  the  attack. 
Actual  fainting  may  often  be  averted  by  taking  a  con- 
trary course,  sitting  with  the  body  forward  and  lowering 
the  head  as  far  as  possible  between  the  knees.  This  not 
only  facilitates  the  circulation  in  the  brain,  but  by  com- 
pressing the  abdomen  expels  a  good  deal  of  blood  which 
is  accumulating  there.  After  a  few  minutes  in  this 
position  the  patient  may  be  sufficiently  recovered  to 
attempt  to  get  up  and  walk  into  the  open  air.  When 
called  upon  to  deal  with  a  patient  who  has  actually 
fainted,  the  first  necessity  is  to  get  him  into  a  horizontal 
position,  to  release  any  clothing  which  may  be  impeding 
free  respiration  and  circulation,  and  to  obtain  as  much 
air  as  is  possible,  at  the  same  time  applying  any 
stimulant  that  may  be  at  hand.  The  application  of 
ammonia  vapour  to  the  nose  is  a  common  remedy,  and 
even  more  effective  is  the  application  of  cold  water, 
especially  to  the  face  and  behind  the  ears,  and  the 
administration  of  a  strong  stimulant  by  the  mouth. 
As  a  fainting  person  is  unable  to  swallow  it  is  best 
to  apply  a  crude  spirit  such  as  brandy  or  eau  de  Cologne 
to  the  inside  of  the  lips  and  gums.  By  these  means 
recovery  may  be  so  far  advanced  that  the  patient  can 
be  slightly  raised  while  he  sips  some  stimulating  fluid. 


Palpitation  157 

The  mere  act  of  sipping  is  in  itself  a  stimulant  even  in  the 
case  of  cold  water,  but  a  more  rapid  stimulating  effect  is 
derived  from  hot  spirit  and  water  in  a  very  small  quantity, 
— about  a  wineglassful. 

Syncope  almost  always  occurs  while  the  patient  is 
inactive,  and  practically  never  during  exertion.  Even  on 
recovery  movement  is  sufficient  to  stimulate  the  circula- 
tion, so  that  there  is  little  fear  of  recurrence  if  the 
patient  is  able  to  walk.  This  tendency  to  fainting  is 
almost  limited  to  adolescence,  and  is  to  be  avoided  by 
discouraging  occupations  of  an  inactive  character  before 
taking  some  nourishment. 

Palpitation. — Apart  from  any  serious  organic  dis- 
order of  the  heart,  occasional  irregularity  of  the  beat  is 
met  with  at  intervals  in  many  healthy  individuals.  These 
disturbances  are  characterised  by  hurried  and  tumultuous 
action,  sometimes  by  what  appears  to  be  an  occasional 
tumble  in  the  cardiac  region,  producing  a  sudden  start 
either  when  waking  or  sleeping.  This  disturbance  nearly 
always  depends  on  some  reflex  impulse  convej^'ed  by  the 
pneumogastric  nerves.  The  most  frequent  instances 
occur  in  minor  forms  of  indigestion,  which  have  been 
already  alluded  to.  It  most  often  ensues  in  connection 
with  gastric  distension,  usually  by  gas,  and  is  occasional 
and  of  only  temporary  duration.  The  treatment  of  this 
necessarily  involves  the  correction  of  the  stomach  dis- 
turbance, and  is  mostly  met  by  antacids,  such  as  the 
compound  of  equal  parts  of  bicarbonate  of  soda,  phosphate 
of  soda,  magnesia,  and  white  sugar,  of  which  a  teaspoonful 
may  be  taken  frequently.  Another  cause  of  common 
occurrence  is  the  over-use  of  tobacco,  especially  in  those 
not  thoroughly  accustomed  to  it.  This  induces  increase 
of  vascular  tension,  and  may  lead  through  this  to  insomnia 
and  to  tumultuous  and  forcible  cardiac  action,  which  is 
particularly  distressing  when  lying  down  at  night,  and 
is  more  noticeable  when  the  patient  lies  on  the  left  side. 


15^  Treatment 

Such  an  effect  after  the  use  of  tobacco,  whether  in  large 
or  small  quantity,  is  an  important  intimation  that  it 
should  be  discontinued  for  a  time  and  certainly  employed 
in  reduced  amounts,  A  persistence  in  tobacco  smoking, 
in  spite  of  this  warning,  leads  to  further  disturbance  and 
dilatation  of  the  heart  with  very  much  more  serious 
symptoms,  which  may  even  prove  fatal.  During  the 
recent  epidemic  of  influenza  there  have  been  very  numer- 
ous cases  in  which  a  cardiac  neurosis  has  taken  the  form 
of  these  attacks  of  palpitation,  accompanied  by  either 
faintness,  nausea,  or  giddiness.  These  do  not  commonly 
extend  over  longer  periods  than  two  or  three  weeks,  but 
in  some  instances  have  settled  down  to  persistent  tachy- 
cardia of  indefinite  duration.  Under  the  influence  of 
emotional  excitement  palpitation  of  the  heart  is  familiar 
to  nearly  every  one,  but  when  brought  about  by  trifling 
psychical  disturbance  it  should  be  regarded  as  an  indica- 
tion for  adopting  a  period  of  rest  or  a  more  even  mode  of 
existence.  For  various  nervous  disturbances  of  the  heart 
cactein  in  the  form  of  pillets,  containing  ^^  of  a 
grain  of  cacteina,  have  been  much  used.  They  may 
be  taken  three  or  four  times  a  day  and  increased  from 
one  to  four  at  a  time.  The  effect  of  overstrain  of  the 
heart  not  uncommonly  results  in  turbulent  action  attended 
with  dyspnoea,  and  is  more  liable  to  occur  where  any 
unwonted  exertion  is  made  without  proper  precaution,  or 
by  adults  who  are  not  accustomed  to  it.  In  connection 
with  mountaineering  it  is  a  familiar  experience  with  some 
to  be  arrested  by  lack  of  breath,  on  commencing  to  climb. 
For  such  the  guide  usually  waits  a  few  minutes,  as  it  is 
only  the  result  of  some  failure  of  the  right  heart  which 
may  presently  recover,  and  the  climber  with  care  is  able 
to  continue  walking  for  several  hours.  On  the  other 
hand,  where  a  general  tremulousness  with  weakness  of 
the  limbs  shows  itself,  the  guide  refuses  to  proceed,  these 
indications  pointing  to  failure  of  the  left  heart,  which  is 


Epistaxis  159 

more  likely  to  be  increased  by  further  exertion,  and  later 
on  lead  to  entire  collapse  of  the  climber.  Many  people 
may  accomplish  by  slow  degrees  what  cannot  be  effected 
in  a  hurry,  and  the  expression,  "It  is  the  pace  that 
kills,"  should  be  borne  in  mind  where  signs  of  cardiac  over- 
strain show  themselves.  It  would  be  wise  if  persons  past 
middle  age,  at  all  events,  could  devote  some  time  to 
training  the  heart  by  moderate  and  varying  exercise 
before  embarking  on  any  violent  or  sustained  exertion. 

Epistaxis. — Nose-bleeding  is  a  very  common  occur- 
rence at  all  ages,  but  particularly  in  children.  Apart  from 
any  injury  it  occurs  as  a  result  of  excitement  and  often 
comes  on  quite  spontaneously.  The  bleeding  is  usually 
restricted  to  one  nostril  and  can  be  traced  to  a  point  about 
f  of  an  inch  within  it,  at  the  junction  of  the  floor  and 
septum.  This  corresponds  to  the  position  of  the  naso- 
palatine artery,  an  anastomotic  vessel  joining  the  internal 
maxillary  and  palatine  arteries,  and  it  is  from  this  or  one  of 
its  branches  that  the  blood  usually  comes.  The  practice  of 
advising  a  patient  to  lie  on  the  back  merely  obscures  the 
haemorrhage  by  permitting  it  to  take  place  into  the 
pharynx,  though  this  position,  by  acting  as  a  sedative 
to  the  heart,  may  have  some  influence  in  arresting  it. 
Physiologically  the  means  of  stopping  such  haemorrhage 
is  by  raising  the  arms  above  the  head.  This  causes  con- 
traction of  the  vessels  of  the  head  and  neck,  and  may 
even  induce  a  feeling  of  faintness.  Another  method  is 
the  application  of  cold  either  behind  the  ears  or  to  the 
nape  of  the  neck.  This  is  commonly  effected  by  a  piece  of 
metal  such  as  a  door  key,  and  is  also  effective  in  bringing 
about  reflex  contraction  of  the  artery. 

Of  local  measures  the  most  immediately  effectual  is 
undoubtedly  the  application  of  a  solution  of  adrenalin, 
1  in  a  1000  or  weaker,  on  a  pellet  of  wool  to  the 
affected  nostril.  It  must  be  inserted  sufficiently  far  to 
reach  the  bleeding  point,  and  for  this  purpose  it  is  best 


i6o  Varicose  Veins  and  Phlebitis 

wrapped  on  a  probe.  Tincture  of  hamamelis,  or  Pond's 
extract,  answers  the  same  purpose,  but  these  m(;asures 
failing  the  nostril  must  be  stopped  efficiently.  The 
old  practice  of  plugging  the  nostril  back  and  front  with 
rolls  of  lint  should  only  be  resorted  to  in  the  last  instance. 
The  cleanest  and  simplest  apparatus  is  an  indiarubber 
bladder  shaped  like  an  hour-glass,  which  can  be  inflated 
with  air  after  insertion,  but  a  very  good  plug  may  be 
rapidly  made  by  shaping  a  piece  of  raw  bacon  fat  to  the 
size  of  the  nostril.  Either  of  these  is  easily  adjusted, 
delays  the  flow  of  bloodsufficiently  to  permit  of  its  clotting, 
and  can  then  be  easily  removed.  The  danger  of  the 
more  complete  older  methods  w  as  the  occurrence  of  sepsis 
which  arises  very  early  in  connection  with  blood  clot  in  a 
cavity  abounding  with  micro-organisms.  After  removal 
of  any  of  these  plugs  the  nostril  should  be  washed  out  with 
an  antiseptic  solution  such  as  has  been  already  mentioned 
in  dealing  with  Catarrh.  Where  epistaxis  occurs  re- 
peatedly, constitutional  remedies  should  be  employed  to 
deal  with  the  cause  of  the  complaint.  In  the  simpler 
cases  mild  purgation  may  be  sufficient,  but  in  those  where 
there  is  a  general  tendency  to  haemorrhage,  as  in  some 
instances  of  chlorosis  or  anaemia  allied  to  scurvy,  it  is 
better  to  administer  lime  salts,  as  chloride  of  calcium, 
in  doses  up  to  a  drachm  daily.  Where  there  are  no 
other  indications  of  haemorrhagic  tendency,  and  bleeding 
recurs  from  the  nose,  a  careful  examination  should  be 
made  to  ascertain  if  there  is  any  local  disease,  such  as 
ulcer  or  angeioma. 

Vapieose  Veins  and  Phlebitis. — Varicose  veins 
are  immediately  apparent,  inasmuch  as  the  vessels  affected 
are  superficial.  They  usually  occur  in  the  lower  ex- 
tremities, more  particularly  on  the  left  side,  and  are  met 
with  at  almost  any  period  of  life,  although  most  frequently 
appearing  between  the  ages  of  twenty  and  thirty.  Here- 
dity seems  to  play  an  important  part  in  the  occurrence 


Treatment  1 6 1 

of  the  condition,  though  anything  which  interferes  with 
the  circulation,  such  as  pregnancy,  may  also  lead  to  their 
development.  Occupations  involving  long-continued 
standing,  habitual  constipation,  and  the  use  of  tight 
bands  round  the  leg  are  very  commonly  accessory 
causes.  The  vessels  become  thickened,  distended,  and 
tortuous,  the  valves  are  rendered  inoperative,  and  the 
weight  of  the  entire  column  of  blood  is  thrown  on  the 
lowermost  veins.  The  circulation  in  the  lower  parts  of 
the  leg  is  often  impaired,  especially  that  in  the  skin.  The 
Hmb  feels  heavy  and  painful,  and  after  exertion  or  stand- 
ing there  may  be  a  little  oedema  of  the  ankle.  The 
circulation  in  the  skin  being  reduced,  pigmentation  and 
eczema  may  result,  and  any  scratch  or  abrasion,  instead 
of  heaUng,  tends  to  spread  and  form  an  ulcer — this  ulcera- 
tion may  extend  through  the  vein  wall,  producing  a  most 
dangerous  hsemorrhage.  Injury  to  the  vein  may  lead 
to  thrombosis  and  spontaneous  cure.  Persons  with 
varicose  veins  are  especially  liable  to  phlebitis  ;  if  limited, 
this  is  not  of  serious  moment,  but  sometimes  the  throm- 
bosis spreads  into  the  larger  veins  while  fragments  of 
clot  may  be  detached  as  emboli. 

On  account  of  these  dangers,  as  well  as  the  discomfort 
attending  varicosity  in  the  veins,  treatment  should  never 
hb  neglected. 

The  treatment  of  this  troublesome  complaint  consists 
in  removing  all  sources  of  obstruction  in  the  form  of 
tight  bandages  or  garters,  restricting  the  amount  of 
standing  and  keeping  the  bowels  well  opened,  together 
with  the  use  of  elastic  bandages  or  stockings.  Shght 
degrees  of  varicosity  can  in  this  way  be  dealt  with,  and 
only  in  the  worst  cases,  in  which  hsemorrhage  occurs 
and  inflammation  is  frequent,  need  surgical  methods 
be  resorted  to.  Nothing  is  gained  by  resting  too  much^ 
movement  rather  helping  the  circulation  than  other- 
wise,   especially    when    support    is    maintained.     As    a 

II 


1 62  Varicocele 

primary  affection,  inflammation  of  the  veins  or  phlebitis 
is  usually  rheumatic  or  gouty,  but  where  coagulation 
of  the  blood  has  already  taken  place  secondary  in- 
flammation of  a  varicose  vein  frequently  follows.  In 
either  case  this  is  associated  with  pain  and  tenderness, 
with  some  local  redness  and  swelUng,  and  is  a  sufficient 
indication  that  the  patient  should  He  up  and  rest  the 
limb.  The  best  local  application  in  such  a  case  is  a 
mixture  of  equal  parts  of  the  ointments  of  belladonna 
and  mercury.  The  limb  should  then  be  slightly  raised 
and  maintained  absolutely  quiet  either  on  a  pillow  or 
in  a  sling.  A  period  of  six  weeks  is  usually  arbitrarily 
allotted  to  the  cure  of  this  affection,  but  half  that  time  is 
often  sufficient  to  allow  the  active  changes  to  subside,  and 
when  there  is  no  oedema,  pain,  or  redness  the  patient  may 
begin  to  get  about  provided  sufficient  pressure  is  main- 
tained on  the  damaged  vessel  to  hinder  the  dislodgment 
of  any  loose  clot.  There  is  not  sufficient  evidence  of 
iodide  of  potassium  exercising  any  influence  in  causing 
disappearance  of  the  coagulum  for  it  to  be  systematically 
recommended,  though  in  gouty  cases  in  combination  with 
salicylate  of  soda  it  may  help  to  control  the  recurring 
phlebitis.  In  rheumatic  cases  salicylate  of  soda  may 
be  given  internally,  though  it  is  better  applied  locally,  as 
Gaultherium  Oil  2  drachms  to  the  ounce  of  Lanoline,  to 
which  15  grains  of  Menthol  may  be  added  to  relieve  pain. 
Where  signs  of  suppuration  occur  hot  fomentations  should 
be  resorted  to,  and  speedy  evacuation  of  matter  en- 
couraged. 

Varieoeele. — This,  in  some  degree,  is  a  very  com- 
mon ailment  though  not  always  recognised  by  the  patient 
and  not  always  mentioned  when  discovered.  Tho  left 
side  seems  most  often  affected  on  account  of  the  rect- 
angular junction  of  the  spermatic  with  the  renal  vein 
not  serving  as  a  valve,  as  is  the  case  with  the  more 
oblique  opening  into  the  cava  on  the  right. 


Varicocele  163 

Patients  with  varicocele  chiefly  complain  of  aching 
and  dragging  pain  referred  to  the  loin  and  abdomen, 
which  may  extend  to  the  leg,  causing  a  sense  of  weariness 
in  standing  and  walking,  attended  sometimes  by  f  aintness 
and  nausea.  An  impulse  may  be  appreciated  on  coughing 
owing  to  the  continuity  of  the  vessel  within  and  outside 
the  abdomen.  The  distension  and  tortuosity  in  the 
upper  part  of  the  scrotum  can  only  be  appreciated 
when  t£e  body  is  erect,  and  this  sometimes  leads  to  its 
being  overlooked  on  examination  when  not  directly 
mentioned. 

A  man  of  thirty  once  consulted  me  on  account  of 
frequent  "  stomach  ache,"  which  occurred  particularly 
when  standing  or  sitting  and  not  while  lying  down. 
Nothing  amiss  could  be  discovered  in  the  abdomen  while 
recumbent  and  no  complaint  was  made  of  the  scrotum.  It 
was  only  by  catching  sight  of  the  distending  veins  as 
he  got  up  that  double  varicocele  was  recognised. 

IVIinor  degrees  of  the  condition  may  be  temporary 
depending  upon  slight  failure  in  the  general  health, 
cough,  straining  at  stool,  or  a  warm  moist  atmosphere, 
and  may  be  remedied  by  cold  bathing,  tonics,  and  support ; 
but  the  severer  and  persistent  degrees  require  careful 
surgical  treatment — ligature  of  the  distended  vein, 
without  injury  to  the  cord,  nerves,  or  artery. 

IJptieapia. — A  capillary  disturbance,  chiefly  notice- 
able in  the  skin  as  Urticaria,  but  liable  to  affect  mucous 
membranes,  especially  those  of  the  larjmx  and  bronchi, 
may  follow  copious  draughts  of  cold  fluid  when  the  body 
is  overheated,  the  ingestion  of  shellfish  and  other  causes 
of  gastric  irritation,  or  the  cutaneous  phenomenon  may 
result  from  sea-bathing  in  susceptible  subjects. 

Immediate  relief  is  usually  obtained  by  taking  ten 
or  fifteen  grains  of  aspirin,  but  it  is  useful  to  employ  a 
brisk  purgative  as  well,  and  in  persistent  cases  ten-grain 
doses  of  calcium  lactate. 


CHAPTER    VI 
THE  MUSCULAR  SYSTEM 

The  muscles  themselves  are  for  the  most  part  free  froix, 
morbid  changes.  The  influence  of  their  contraction  on 
the  vascular  system  is  not  always  sufficiently  appre- 
ciated, though  this  is  considerably  modified  by  physical 
activity.  The  blood  may  be  considered  to  be  divided 
principaUy  between  the  skin,  muscles,  and  viscera.  Con- 
sequently a  reduction  of  blood  in  the  skin  as  a  result 
of  cold,  and  in  the  muscles  as  a  result  of  cold  or  of 
inactivity,  permits  of  an  undue  quantity  of  this  fluid 
being  distributed  to  the  internal  organs.  Physiologically 
this  may  be  of  value  in  such  circumstances  as  digestive 
or  special  brain  activity  in  which  there  is  a  tendency  to 
chilliness  or  actual  coldness  of  the  extremities  while  the 
main  current  of  blood  is  so  diverted. 

In  the  treatment  of  chronic  valvular  disease  of  the 
heart  by  the  Nauheim  system  of  baths  and  exercise,  the 
distribution  of  blood  in  the  skin  and  muscles  by  surface 
stimulation  and  rhythmical  movements  is  taken  advantage 
of  to  relieve  the  tension  of  the  circulation  and  the  work 
of  the  heart  by  widening  the  channels  of  peripheral 
distribution.  On  these  lines  the  value  of  moderate 
exercise  to  the  point  of  causing  extra  vascularity  and 
functional  activity  of  the  skin  and  muscles  may  easily 
be  appreciated  in  the  reUef  they  afforc?  to  the  heart  and 
the  extra  freedom  in  the  circulation  oi  x;he  blood  through 
the  lungs  and  body  generally. 

It  is  a  peculiarity  of  the  arrangement  of  the  vessels 

164 


Muscular  System  165 

within  and  between  the  muscles  that  functional  activity- 
tends  to  cause  dilatation  rather  than  compression  of  them, 
and  as  most  of  the  cutaneous  vessels  are  derived  from 
muscular  branches,  the  vascularity  of  the  two  systems 
is  affected  synchronously. 

A-  very  suggestive  feature  in  connection  with  the 
muscles  is  the  presence  in  them  of  haemoglobin,  to  which 
their  colour  is  largely  due,  and  which  varies  considerably 
in  different  states  of  the  organism.  For  instance,  in 
cases  where  death  has  been  associated  with  cyanosis 
the  muscles  are  very  dark,  while  in  those  associated 
with  deficiency  of  haemoglobin  in  the  blood  they  are 
very  pale  ;  indicating  that  the  haemoglobin  of  muscle 
shares  the  changes  of  the  blood.  Individuals  with  large 
muscles  are  usually  plethoric  and  those  with  small 
muscles  commonly  pale  and  exsanguine.  That  haemo- 
globin may  possibly  be  stored  in  the  muscles  and  trans- 
ferred to  the  blood  is  suggested  by  the  case  of  a  man 
recently  under  treatment  by  enemata  of  water  only  on 
account  of  gastric  ulcer  with  haemorrhage,  in  whom 
distinct  improvement  in  colour  and  the  character  of 
the  blood  occurred  during  a  fortnight's  entire  abstinence 
from  food. 

The  function  of  haemoglobin,  whether  in  the  blood  or 
muscles,  is  chiefly,  if  not  entirely,  as  a  holder  of  available 
oxygen,  and  the  marked  effect  of  muscular  exertion  in 
producing  dyspnoea  either  in  health  or  disease  is  striking 
evidence  of  the  activity  of  oxidising  processes  in  con- 
nection with  muscle  activity.  It  is  also  a  well-known 
fact  that  in  those  who  show  a  tendency  to  gout,  acute 
attacks  are  specially  liable  to  occur  during  periods  of 
physical  inaction — that  is,  while  the  metabolic  changes 
in  the  muscles  are  suspended. 

The  beneficial  effect,  therefore,  of  regular  physical 
exercise  must  be  attributed  to  the  intrinsic  influence  of 
muscular  metabolism  on  nutrient  matters  in  the  blood 


1 66  Sprains 

leading  to  their  complete  oxidation  as  well  as  to  the 
assistance  their  alternate  contraction  and  relaxation 
afford  to  the  circulation  in  the  arteries,  veins,  and  lym- 
phatics, and  the  stimulating  effects  on  the  functions  of 
the  heart,  lungs,  and,  indirectly,  the  excretory  organs. 
On  account  of  the  abundant  demand  for  oxygen  entailed, 
such  exercise  should  be  taken  preferably  in  the  open, 
and  in  the  purest  available  air  with  careful  avoidance 
of  tight  clothing  or  anything  impeding  respiration,  and 
should  be  accompanied  by  a  plentiful  supply  of  fluid 
to  encourage  the  solution  and  excretion  of  effete  products 
— these  requirements  being  in  accord  with  the  familiar 
indications  of  nature. 

Sprains. — Although  the  muscular  tissue  itself  is  but 
slightly  prone  to  disease,  the  sheaths,  the  tendons,  and 
the  aponeuroses  are  very  susceptible  to  slight  injury,  and 
the  influence  of  such  diathetic  states  as  rheumatism  and 
gout.  In  consequence  of  undue  efforts,  associated 
rather  with  mal-position  and  falls  than  with  simple 
muscular  contraction,  the  tendons  are  Kable  to  give  way 
or  to  suffer  partial  disturbance  of  their  attachments, 
giving  rise  to  injuries  known  as  "  sprains." 

The  term  "  sprain,"  commonly  applied  to  local 
injury  resulting  from  over-flexion  or  extension  of  a 
joint,  necessarily  involves  stretching  and  injury  to  other 
tissues  than  the  tendons,  notably  the  ligaments  and 
joints,  as  well  as  the  parts  covering  them.  Sudden  and 
continued  pain  as  well  as  swelling  and  tenderness  are  the 
usual  accompaniments,  and  it  is  somewhat  remarkable 
that  though  such  fibrous  structures  as  these  are  ordinarily 
insensitive,  they  develop  acute  sensitiveness  with  extra 
tension  and  inflammation.  No  small  share  in  the  sub- 
sequent effects  of  sprains  is  taken  by  the  synovial  mem- 
branes and  tendon  sheaths.  Effusion  occurs  into  both, 
so  that  some  degree  of  synovitis  and  teno-synovitis  is 
added.     Sprains,    then,    are   complex   lesions,    short   ol 


Treatment  of  Sprains  167 

actual  fracture  of  the  bones,  or  rupture  of  ligamentous 
structures,  involving  deep-seated  haemorrhage  from 
laceration  of  soft  tissues  and  reactionary  inflammation, 
though  the  actual  limit  of  damage  cannot  always  be 
estimated,  and  many  severe  sprains  are  found  after  some 
time  to  involve  actual  detachment  of  portions  of  bone, 
or  rupture  of  tendinous  structures.  The  uncertainty 
as  to  the  extent  of  such  a  lesion  suggests  the  inadvisa- 
bility  of  putting  any  strain  on  the  affected  part  until 
recovery  is  secure.  In  those  slight  cases  in  which  the 
immediate  pain  subsides  in  a  few  minutes,  and  is  followed 
by  no  obvious  sweUing,  such  precautions  are  uimecessary, 
but  a  few  moments'  rest  will  generally  decide  whether 
any  serious  damage  has  been  done  by  the  development 
or  otherwise  of  swelling.  Should  this  occur  the  joint 
must  be  fixed  in  a  position  of  comfortable  rest,  and  cold 
applied  by  means  of  wet  cloths  or  an  evaporating  lotion. 
The  old-fashioned  remedy,  tincture  of  arnica,  is  still 
often  used,  and  its  effect  in  cooKng  the  part  by  evapora- 
tion of  the  alcohol  may  itself  be  useful. 

SHght  sprains  may  be  remedied  by  firmly  embracing 
the  joint  in  every  part  with  strapping,  preferably  of  thin 
leather  or  kid,  which  sets  a  limit  to  movements  and 
affords  support  without  entirely  disabling  the  hmb. 

Of  all  the  joints  probably  the  ankle  is  the  one  most 
commonly  the  seat  of  this  injury,  owing  to  its  receiving 
the  entire  weight  of  the  body,  and  the  involuntary  attempt 
to  rectify  mal-position  by  sudden  tension  of  the  controlling 
muscles.  A  very  common  feature  of  these  injuries  is 
the  rupture  of  the  tendon  of  the  peroneus  tertius,  which 
results  from  sudden  forcible  inversion  of  the  foot.  The 
occurrence  of  this  lesion  can  generally  be  traced  by  a 
line  of  tenderness  extending  to  the  base  of  the  fifth 
metatarsal  bone,  also  by  ecchymosis  here,  and  the  notice- 
able absence  of  the  tendon  when  the  foot  is  raised.  In 
most  instances  the  breakage  is  made  good  by  organise- 


1 68  Synovitis 

tion  of  efFusion  in  the  sheath  which  occurs  in  a  few 
weeks. 

Synovitis. — The  effusion  of  an  extraordinary  amount 
of  fluid  in  a  joint,  usually  as  a  result  of  over-use  or  a  blow, 
accompanied  by  some  degree  of  pain,  is  a  matter  of  com- 
mon occurrence  and  one  which  is  too  often  neglected. 
When  effusion  occurs  within  an  hour  of  such  injury,  it 
is  most  often  due  to  blood,  the  increase  of  synovial  fluid 
taking  a  longer  time.  As  the  degree  of  pain  in  either 
case  may  not  be  intense  nor  protracted,  patients  are 
very  apt  to  neglect  the  mere  stiffness  and  swelling  pro- 
duced by  the  effusion,  and  by  continued  use  to  render 
such  either  chronic  or  recurrent.  Simple  synovitis  is 
usually  distinguished  from  that  due  to  rheumatism  or 
gout  by  the  relative  absence  of  pain,  and  by  a  single  joint 
only  being  affected.  The  important  element  of  treatment 
is  rest,  the  limb  being  placed  in  the  position  of  greatest 
comfort,  usually  half  flexed,  and  well  supported.  In  case 
of  restlessness,  it  may  be  necessary  to  place  it  upon 
a  splint,  extending  sufflciently  far  above  and  below  to 
fix  the  articulation  and  muscles.  Not  only  should  move- 
ment be  prevented,  but  the  patient  should  be  discouraged 
from  exerting  any  pressure  on  the  joint,  as  in  walking 
with  a  stiff  leg.  Local  applications,  first  cooling,  such  as  an 
ice-bag  or  evaporating  lotion,  are  best,  and  subsequently 
some  form  of  counter-irritation,  such  as  preparations  of 
iodine  or  a  dilute  ointment  of  the  red  iodide  of  mercury, 
5  or  10  grains  to  the  ounce.  In  the  case  of  smaller 
joints,  especially  of  the  hand,  the  application  of  counter- 
irritation  alone  may  be  sufficient. 

Teno-Synovitis. — Effusion  into  the  sheath  of  a 
tendon  most  commonly  results  from  over-use,  particularly 
in  the  forcible  or  continued  use  of  some  particular  move- 
ment. It  is  met  with  most  frequently  in  the  wrist  and 
hand,  more  particularly  the  thumb,  and  it  is  characterised 
hj  tenderness  and  swelling  in  the  course  of  certain  tendons, 


Teno^Synovitis  169 

the  movements  of  which  become  stiff  and  painful.  The 
rest  obtained  by  a  bandage  exerting  moderate  pressure 
is  usually  sufficient  to  allay  this,  provided  the  particular 
movement  is  desisted  from. 

Obscure  pains  and  areas  of  tenderness  in  connection 
with  the  muscular  system  are  often  traceable  to  bursitis. 
Many  of  the  superficial  bursse  are  sufficiently  well  known, 
and  effusion  into  them  produces  such  noticeable  swelling 
that  they  are  not  easily  overlooked,  but  the  deeper  ones 
are  more  difficult  to  define,  and  it  is  rather  by  the  situation 
and  occurrence  of  the  pain,  in  association  with  particular 
muscular  movements,  that  the  complaint  is  apparent. 
Common  situations  for  trouble  in  these  spaces  are  the 
outer  side  of  the  hip,  beneath  the  tensor  vaginae  femoris, 
over  the  ischial  tuberosity,  under  the  insertion  of  the 
glutei  muscles  both  behind  and  outside  the  trochanter, 
above  the  insertion  of  the  ilio-psoas  muscle,  about  the  knee, 
and,  perhaps  most  obscure  of  all,  the  large  bursal  space 
lying  between  the  gastrocnemius  and  soleus  in  the  calf 
of  the  leg.  These  bursse  are  liable  to  inflammation  and 
effusion,  in  consequence  of  over-use  and  fatigue,  and  are 
sometimes  affected  by  local  pressure,  or  by  gouty  or 
rheumatic  inflammation. 

The  inflammation  of  the  sural  bursa  has  indeed  often 
been  mistaken  for  phlebitis.  Traumatic  bursitis  may  be 
relieved  by  counter-irritants  and  rest,  and  that  of  over-use 
and  fatigue  usually  subsides  with  prolonged  inactivity 
of  the  muscles,  but  is  one  of  the  causes  of  pain  and  aching 
which  follow  protracted  exertion.  Bursitis  arising  in 
connection  with  gout  or  rheumatism  must  be  treated 
as  part  of  this  complaint,  and  in  the  case  of  sural 
bursitis  the  most  rapid  cure  is  effected  by  the  local 
application  of  salicylate  of  methyl  in  fomentations  or 
ointment. 

Some  of  the  commonest  instances  of  bursitis,  synovitis, 
?ind  teno-synovitis   are   afforded   by   such   local   lesions 


1 70  Bruises 

resulting  from  special  use  of  particular  joints,  as  golfer's 
shoulder,  tennis  and  fisherman's  elbow. 

Bpuises. — The  extravasation  of  blood  beneath  and 
into  the  skin  as  the  result  of  contusion  is  usually 
regarded  as  irremediable,  and  for  the  most  part  having 
passed  through  successive  colour  transformations  it 
disappears,  and  causes  no  inconvenience  beyond  transitory 
tenderness.  In  some  situations,  however,  it  may  be  of 
importance  to  avoid  discoloration,  which  lasts  for  a 
week  or  more.  This  can  only  be  done  by  preventing 
exudation  of  blood  at  the  time  of  injury,  by  cold  or  pres- 
sure. The  avoidance  of  a  "  black  eye  "  after  a  contusion 
by  the  firm  apphcation  of  a  piece  of  raw  beef-steak  is 
time-honoured,  and  fairly  effectual.  A  pad  of  cotton- 
wool, soaked  in  cold  water,  is  cleaner  and  as  efficient, 
but  to  be  effective  the  application  must  be  made  immedi- 
ately, and  continued  for  a  couple  of  hours  at  least.  There 
are  no  means  of  hastening  the  removal  of  bruises  which 
are  once  established  and  are  passing  through  their  colour 
gradations. 

Myalgia. — Pain  associated  with  movement  in  the 
region  of  the  muscular  attachments,  and  excited  by 
contraction,  does  not  necessarily  involve  actual  change  in 
the  muscle-fibre  itself,  and  forthemostpart  such  pain  comes 
and  goes  without  any  recognisable  change  in  the  size  of  the 
muscle,  and  without  leaving  any  sequel  such  as  fixation 
or  loss  of  bulk.  Tenderness  on  pressure  there  may  be  at 
times,  but  even  this  is  rare  and  but  slightly  developed, 
the  main  feature  being  pain  more  or  less  sharp  attending 
movements  in  which  the  particular  muscle  or  group  of 
muscles  is  involved,  persisting  but  a  second  or  two  after 
the  contraction  has  ceased,  the  intervals  being  quite 
free  of  discomfort  or  attended  with  but  subdued  aching. 
It  may  fairly  be  assumed,  then,  that  the  change  consists 
in  an  alteration  of  vascularity  with  some  excess  of  exuda- 
tiion,  interfering  with  the   free   movement   of   adjacent 


Myalgia  1 7 1 

structures,  but  restricted  almost  entirely  to  the  fibrous 
parts,  such  as  the  attachments,  sheaths,  aponeuroses, 
and  septa.  In  a  considerable  number  of  cases,  termed 
myalgia  or  muscular  rheumatism,  the  onset  of  the  attack 
can  be  traced  to  cold,  or  cold  associated  with  wet,  to 
which  the  particular  part  has  been  exposed.  Such  attacks 
are  more  often  unilateral,  affecting  particularly  the  side 
of  the  neck,  constituting  what  is  known  as  a  "  sti£f  neck," 
or  the  muscles  about  the  shoulder  or  hip.  These  attacks 
may  be  protracted  over  three  or  four  days,  causing  limi- 
tation of  movement,  and  appearing  worse  after  prolonged 
rest,  as  on  first  waking  in  the  morning.  Other  attacks, 
similar  in  many  respects,  affect  the  muscles  of  the  trunk, 
more  particularly  in  the  upper,  middle,  and  lower  parts 
of  the  back,  and  for  the  most  part  come  on  spontaneously 
and  are  commonly  discovered  on  making  some  extra- 
ordinary movement.  These  spontaneous  attacks,  which 
are  indeed  constitutional  in  origin,  occur  both  in  hot  and 
cold  weather,  often  in  the  absence  of  exercise,  and  depend 
upon  toxaemia,  usually  associated  with  defective  func- 
tional activity  in  the  digestive  tract,  consequently  they 
should  not  be  treated  nor  regarded  merely  as  local 
affections.  They  are  best  remedied  by  mercury  or 
calomel  in  2  or  3-grain  doses,  followed  by  salines.  The 
salicylates  and  especially  aceto-salicylic  acid  may  be 
subsequently  administered  internally,  or  the  salicylate 
of  methyl,  2  drachms  to  the  ounce  of  wool  fat,  applied 
locally,  as  the  pain  does  not  always  entirely  subside, 
though  the  acuteness  is  remarkably  reduced  by  the  mer- 
curial treatment.  Though  these  local  pains  are  spoken  of 
as  muscular  rheumatism,  they  are  unattended  by  any 
rise  in  temperature  as  in  the  articular  disorder,  and  are 
not  at  any  time  associated  with  other  recognisable  mani- 
festations of  rheumatism.  The  fact  that  the  salicylates 
are  helpful  in  remedying  the  complaint  is  no  evidence  of 
its  being  rheumatic,  since  these  drugs  are  known  to  act 


172  Myalgia 

efficiently  in  promoting  the  flow  of  bile  and  so  prolong  tlie 
effect  of  the  mercury.  Of  all  local  measures  none  are  so 
efficient  as  the  application  of  heat  and  massage.  A 
turpentine  stupe  applied  for  twenty  minutes  is  often 
both  comforting  and  curative.  More  generally  distributed 
pains,  associated  with  slight  rise  of  temperature,  are 
liable  to  recur  from  time  to  time  in  both  adolescents  and 
people  of  middle  age.  This  general  fibrositis  in  the  young, 
often  referred  to  as  "  growing  pains,"  is  not  infrequently 
a  rheumatic  manifestation  and  deserves  more  serious 
attention  than  it  commonly  receives  on  account  of  the 
possible  involvement  of  the  heart,  a  matter  of  special 
importance  at  this  age.  In  older  people  recurrent  attacks 
of  general  pain  in  the  muscles  are  usually  referred  to  in- 
fluenza, but  the  fever  is  slighter,  general  nervous  pro- 
stration less,  and  the  rapidity  of  recovery  greater  than 
in  that  complaint.  Discrimination  between  the  two  is 
more  important  since  influenza  requires  rest,  and  subse- 
quent supporting  regimen,  while  this  general  form  of 
fibrositis  rather  calls  for  exercise  and  reduced  diet,  with 
diminution  of  stimulants.  The  pains  in  influenza  are 
distributed  mainly  in  the  back,  less  in  the  extremities, 
are  particularly  intense,  and  associated  generally  with 
a  temperature  above  103°  .  The  pains  in  what  is 
probably  toxic  fibrositis  are  more  widely  distributed, 
persist  for  two  or  three  days,  and  are  unassociated  with 
fever  beyond  a  degree  or  two. 

What  has  often  been  termed  a  "  crick  in  the  neck  " 
is  occasioned  by  some  forcible  and  unguarded  movement, 
or  more  often  by  sleeping  in  an  attitude  which  allows  of 
persistent  over-extension  of  some  of  the  articulations. 
It  often  follows  the  use  of  too  high  a  piUow  when  lying 
on  the  side.  The  pain  is  due  to  over-extension  of  liga- 
ments and  articular  surfaces,  and  is  initially  traumatic, 
but  diathetic  states  are  prone  to  express  themselves  in 
such  slightly  damaged  localities  and  to  render  the  pain 


Cramp  173 

more  lasting  than  it  would  otherwise  be.  It  is  hardly 
necessary  to  refer  to  the  treatment  of  so  slight  a  trouble 
except  to  point  out  its  causation  so  that  it  may  be 
avoided,  and  recourse  should  be  had  to  remedies  already 
mentioned  when  constitutional  disturbance  is  responsible 
for  persistence  of  the  pain. 

Cpamp. — This  consists  in  painful  sustained  involun- 
tary contraction  of  muscles  or  groups  of  muscles,  usually 
associated  with  fatigue  or  toxaemia.  In  the  latter  case 
it  may  be  associated  with  convalescence  from  cholera, 
influenza,  or  other  acute  fevers,  and  may  take  the  form 
of  tetany  of  the  upper  limbs. 

Attacks  of  cramp  for  the  most  part  affect  muscles 
whose  attachments  are  approximated  either  actively 
or  passively,  and  pass  off  with  extension  of  the  affected 
muscles  and  massage.  When  recurrences  are  frequent, 
warm  bathing,  antacids,  and  free  imbibition  of  water 
assist  in  banishing  them.  The  extremities  are  most 
commonly  affected,  but  portions  of  the  rectus  abdominis, 
the  platysma,  extrinsic  muscles  of  the  tongue,  or  other 
groups  may  be  affected,  producing  peculiar  discomfort. 


CHAPTER  VII 

SPECIAL  SUBJECTS 
THE  EYE 

Foreign  bodies  in  the  conjunctival  sac  constitute 
a  very  common  source  of  discomfort,  and  are  more 
formidable  when,  as  frequently  happens,  gritty  par- 
ticles become  embedded  in  the  surface  of  the  cornea. 
Their  detection  requires  the  use  of  a  lens,  a  good  light, 
and  the  employment  of  a  local  anaesthetic,  of  which  the 
best  for  general  use  is  a  solution  of  10  grains  of  cocaine 
in  an  ounce  of  castor  oil.  By  these  means  a  minute 
examination  may  be  made,  and  the  half-buried  particle, 
when  discovered,  should  be  removed  carefully  with  a 
small  spud,  the  eye  being  subsequently  closed  and 
covered  with  a  wet  pad.  Such  injuries  most  often  result 
from  cinders  in  the  course  of  a  railway  journey,  which 
leave  small  ulcers,  taking  twenty-four  to  forty-eight  hours 
to  heal.  Over  this  period  the  occasional  use  of  cocaine 
in  oil  is  of  great  service. 

A  foreign  body  in  the  conjunctival  sac  is  easily  exposed 
when  in  the  lower  part  by  pulling  down  the  lid  while  the 
eye  is  directed  upwards.  In  the  upper  portion  a  thorough 
examination  is  not  so  easy,  as  even  if  the  lid  be  completely 
everted  the  upper  portion  of  the  sac  still  remains  un- 
exposed. By  gently  tilting  the  everted  lid  while  the 
globe  is  rotated  downwards  a  foreign  body  there  situated 
is  usually  brought  into  view.  A  small  wet  pledget  of 
wool  or  camel-hair  brush  offers  the  best  means  of  sweeping 
the  object  off  the  conjunctiva.  In  many  instances  by 
merely  pulling  the  upper  lid  downwards  over  the  lower 

174 


Conjunctivitis  1 7  5 

so  that  its  inner  surface  may  be  swept  by  the  lower  lashes, 
a  foreign  body  in  this  situation  is  at  once  removed,  or  at 
all  events  displaced.  Unless  embedded  in  the  conjunctiva 
or  cornea  most  particles  if  left  to  themselves  are  swept 
oy  the  natural  stream  of  tears  into  the  inner  corner  of 
the  aye,  where  they  cease  to  annoy.  Rubbing  the  eye 
should  especially  be  avoided. 

Dust  or  infective  material  may  lead  to  certain  forms 
of  septic  inflammation,  which  often  convey  to  the  patient 
the  same  impression  as  grit  in  the  eye,  with  hyperasmia 
of  the  mucous  membrane,  increased  flow  of  tears,  and 
often  some  flakes  of  lymph,  which  may  be  sufficient  to 
cause  the  Kds  to  adhere. 

The  milder  forms  of  eonjunetivitis,  with  muco- 
purulent or  catarrhal  exudation,  being  contagious,  some- 
times occur  in  epidemics,  especially  in  schools.  They  are 
best  treated  by  mild  astringent  or  antiseptic  lotions,  such  as 
1-5,000  solution  of  perchloride  of  mercury,  a  10  per  cent, 
solution  of  boric  acid  or  borax  in  distilled  water,  hazeline 
tiX  XX  to  5  j,  acetozone  or  zinc  chloride  |  grain  to  the  ounce, 
the  acetozone  solution  being  filtered  after  standing  four 
hours.  To  prevent  the  edges  of  the  lids  from  sticking 
together,  a  simple  ointment  such  as  that  of  boracic  acid 
should  be  applied  along  the  edges  of  the  lids  at  night. 
Isolation  is  necessary  to  prevent  extension  of  the  disease 
to  others. 

In  the  more  severe  attacks  attended  by  purulent  dis- 
charge, more  drastic  measures  are  necessary,  such  as  the 
apphcation  of  a  solution  of  nitrate  of  silver  10  grains  to 
the  ounce,  or  of  protargol  15  grains  to  the  ounce,  applied 
once  to  the  conjunctival  sac,  followed  by  a  continuance 
of  the  treatment  by  boracic  solution  and  ointment.  A 
septic  form  of  conjunctivitis,  commencing  in  one  eye, 
though  commonly  affecting  both,  is  frequently  met  with 
in  cities  during  the  summer  as  a  result  of  infection  by  foul 
dust  from  wood  pavements. 


176  Phlyctenular  Conjunctivitis 

Another  form,  especially  common  in  children,  is 
phlyetenulap  eonjunetivitis,  characterised  by  the 
presence  on  the  ocular  conjunctiva  at  the  edge  of  the  cornea 
of  small  white  tubercle-Uke  collections  of  leucocytes  sur- 
rounded by  a  hmited  vascular  zone,  into  which  a  leash  of 
dilated  vessels  can  be  traced  across  the  white  part  of  the 
globe.  It  is  usually  accompanied  by  photophobia  and 
lachrymation,  and  is  best  treated  by  the  local  application 
of  yellow  mercuric  oxide  ointment  gr.  iv-viij  to  the  ounce 
in  soft  paraffin,  or  by  calomel  locally,  and  a  general  tonic 
regimen,  with  an  open-air  hfe. 

Small  haBmopphag'es  in  the  conjunctiva  are  very 
conspicuous  on  account  of  the  bright  colour  developed  by 
oxidation  of  the  haemoglobin  through  the  thin  membrane. 
They  often  accompany  attacks  of  conjunctivitis,  and  may 
result  from  the  paroxysms  of  whooping-cough  or  some 
local  injury.  They  usually  disappear  in  the  course  of 
a  few  days  without  any  treatment. 

Episelepitis,  an  inflammation  of  the  fibrous  tunic  of 
the  eye,  producing  a  reddish  purple  patch,  usually  between 
the  cornea  and  outer  canthus,  sometimes  results  from 
exposure  to  cold  as  in  motoring ;  it  is  apt  to  last  for  some 
months,  and  to  relapse.  Pain  and  tenderness  are  variable, 
but  inflammation  may  extend  to  the  interior  of  the  eye. 
It  is  more  often  met  with  in  women  than  in  men,  and  is 
generally  associated  with  a  rheumatic  or  gouty  diathesis. 
Locally  warm  fomentations,  with  opium,  massage,  and 
leeches  to  the  temple,  may  be  required,  but  the  main 
treatment  consists  in  the  administration  of  sahcylate  of 
soda,  iodide  of  potassium,  or  other  constitutional  remedy 
appropriate  to  the  systemic  conditions. 

Ciliapy  blephapitis  or  Tinea  Tarsi,  a  common  in- 
flammatory afiection  of  the  lid  margins,  is  usually  chronic, 
and  either  follows  some  acute  fever  or  is  associated  with 
refractive  errors  or  some  general  constitutional  disturb- 
ance.    The    ciliary  border  is  red  and   eczematous,    and 


Meibomian  Cyst  177 

more  or  less  destruction  of  the  eyelashes  is  produced  by  the 
inflammation  extending  to  the  hair  follicles.  The  best 
treatment  is  afforded  by  an  alkaline  solution  such  as  that 
of  bicarbonate  of  soda  15  grains  to  the  ounce,  with  a 
weak  mercurial  ointment  such  as  Unguentum  Hydrargyri 
Nitratis,  1  drachm,  diluted  with  7  drachms  of  white 
vaseline,  applied  along  the  edges  of  the  lids  night  and 
morning.  In  severe  cases  benefit  results  from  removal 
of  the  damaged  lashes  and  painting  the  borders  of  the  lids 
with  a  solution  of  silver  nitrate  10  grains  to  the  ounce. 

Meibomian  eyst,  resulting  from  chronic  inflamma- 
tion of  the  deep  part  of  a  Meibomian  gland,  with  retention 
of  secretion,  is  the  commonest  form  of  tumour  of  the 
lid.  It  forms  a  small  hard  white  and  painless  swelling 
beneath  the  skin,  and  on  everting  the  tarsus  a  bluish 
spot  is  usually  seen,  marking  its  site.  Treatment 
consists  in  incising  this  spot,  and  evacuating  the  fluid 
and  solid  contents  by  pressure  or  a  small  scoop  on 
the  conjunctival  surface.  Such  a  cyst  may  suppurate, 
and  must  then  be  evacuated.  Others  may  appear, 
whether  the  first  be  removed  or  not.  They  may  be  left 
alone  unless  very  conspicuous,  and  in  time  usually  shrink 
to  some  extent. 

More  common  are  the  small  hard  sebaceous  or  epi- 
thelial  collections  at  the  orifices  of  the  glands  at  the  lid 
margins  internal  to  the  lashes,  which  appear  as  little 
yellowish  white  spots  slightly  raised  above  the  edge  of 
the  Ud.  They  are  either  soft  or  gritty,  and  may  some- 
times be  gently  picked  or  rubbed  off.  They  only  rarely 
give  rise  to  slight  irritation. 

Stye  has  been  already  mentioned  in  connection  with 
furunculosis  of  the  skin.  Tophi  sometimes  develop  in 
connection  with  the  tarsal  cartilages  as  in  the  auricle, 
and  may  be  similarly  dealt  with,  but  they  are  best  left 
alone. 

Al  trifling  ailment  is  a  slight  shimmering  of  the  orbi- 

12 


1 78  Musc3e  Volitantes 

cularis  muscle  occurring  involuntarily  at  certain  times. 
It  has  been  spoken  of  as  "  live  blood  "  and  its  occurrence 
is  an  indication  for  the  use  of  mild  mercurial  purgatives 
and  salines. 

The  yellowish  dry  patches  appearing  at  the  inner 
corner  of  the  upper  lid,  known  as  xanthelasma,  are  some- 
times regarded  as  an  indication  of  chronic  liver  disturbance 
and  are  best  left  untreated  locally. 

MuseSB  Volitantes. — Black  or  grey  spots  floating 
in  the  field  of  vision  are  commonly  discovered  by  ado- 
lescents at  some  time,  and  can  be  observed  by  many 
individuals  throughout  life  when  looking  at  a  plain 
Hght  surface  such  as  a  white  wall  or  cloud,  or  when  read- 
ing or  working  with  the  microscope.  They  represent 
small  particles  in  the  vitreous  and  follow  to  some  extent 
the  motions  of  the  eye.  Beyond  being  the  cause  of  some 
concern  when  first  discovered  and  becoming  more  ob- 
trusive with  defects  of  health,  they  are  of  no  importance, 
and  attention  should  be  diverted  from  them.  Synchisis 
scintiUans  is  a  somewhat  similar  condition  due  to  minute 
flakes  of  cholesterine  in  a  fluid  vitreous,  possibly  derived 
from  a  small  haemorrhage.  The  appearance  is  likened 
to  a  shower  of  ghttering  particles  with  each  movement 
of  the  eye,  and  has  been  compared  with  that  of  the  hqueur 
known  as  Eau  de  Dantzig  when  viewed  with  the  oph 
thalmoscope.     It  is  not  amenable  to  treatment. 

It  is  a  common  experience  after  receiving  a  blow  on 
the  head  or  a  sudden  jar  of  the  body  to  "  see  stars,"  or 
floating  scintillations  for  a  few  seconds.  This  is  probably 
associated  with  concussion  in  the  optic  tracts,  as  it  is 
equally  apparent  when  the  eyes  are  closed  and  subsides 
rapidly. 

Some  interference  with  vision  accompanied  by  a  sense 
of  irritation  in  the  eyes  not  infrequently  follows  exposure 
to  strong  light,  such  as  the  glare  reflected  from  snow  or 
water,  or  from  looking  directly  at  electric  lamps  or  the 


The  Ear  179 

sun,  and  some  years  ago  was  commonly  known  as  "  eclipse 
blindness "  on  account  of  the  number  of  persons  so 
affected  by  viewing  an  eclipse  of  the  sun  without 
adequate  protection.  It  results  from  fatigue  of  the 
retina,  and  passes  off  with  time  and  protection  from 
bright  light. 

THE  EAR 

The  diseases  of  the  ear  which  will  be  considered  are 
chiefly  characterised  by  pain,  discharge,  and  either 
partial  loss  of  hearing  or  the  development  of  subjective 
sensations. 

The  auricle  being  composed  almost  entirely  of  skin 
or  fibro-cartilage  may  be  involved  in  the  disorders 
peculiar  to  the  dermal  covering,  such  as  eczema,  herpes, 
etc.  These  do  not  call  for  any  treatment  other  than  that 
applied  to  the  rest  of  the  skin. 

Deposits  which  are  peculiar  to  the  pinna  are  small 
chalk  stones  composed  of  urate  of  soda,  regarded  as  an 
indication  of  gout,  and  which  sometimes  itch  slightly. 
They  may  either  be  picked  out  when  superficial  or  ab- 
sorbed by  compresses  of  carbonate  of  soda  or  lithium 
solution.  Another  is  haematoma,  resulting  often  from 
injury,  and  made  up  of  blood  effusion  between  the 
cartilage  and  skin.  This  usually  subsides  to  a  great 
extent  spontaneously,  though  often  leaving  some  thicken- 
ing which  is  rather  conspicuous.  It  may  therefore  be 
considered  worth  while  to  aspirate  such  effusions,  with 
aseptic  precautions,  but  should  suppuration  occur,  as  occa- 
sionally happens,  an  incision  must  be  made  to  free  the  pus. 

The  meatus  is  hable  to  inflammation  from  direct 
injury,  particularly  in  scratching  or  attempts  to  remove 
foreign  bodies,  and  sometimes  by  extension  of  skin  disease 
from  the  scalp.  This  is  productive  of  pain  and  subse- 
quently discharge,  and  where  the  lumen  is  obstructed 
may  involve  some  temporary  loss  of  hearing.     There  are 


1 80  Furuncles 

redness  and  swelling  of  the  skin  round  the  meatus,  a  sense 
of  fulness,  throbbing,  and  occasional  tinnitus,  followed 
by  serous  or  sero-purulent  discharge.  The  epithelium 
becomes  white  and  swollen,  occupying  a  considerable 
portion  of  the  lumen,  and  separates  in  flakes.  Pain  is 
increased  by  movement  of  the  jaw  or  pressure  over  the 
ear,  and  there  may  be  a  sense  of  itching  and  heat,  some- 
times attended  by  shght  fever.  These  developments 
may  follow  the  penetration  of  flies  and  other  insects  into 
the  meatus,  or  the  introduction  of  water  when  bathing. 
In  the  initial  stage  a  cold  compress  or  astringent  lotion 
will  give  some  relief.  When  the  secretion  is  established 
the  meatus  should  be  washed  out  with  a  warm  solution 
of  boracic  acid  10  grains  to  the  ounce,  and  later  with 
equal  parts  of  alcohol  and  water  ;  or  powdered  boracic 
acid  may  be  blown  in  with  the  aid  of  a  small  screw  of 
paper.  Should  the  discharge  continue,  the  surface  may 
be  painted  with  solution  of  nitrate  of  silver  30  grains  to 
the  ounce,  Liquor  Plumbi  Subacetatis,  or  Ung.  Hydrarg. 
Subchlor.  1  drachm  to  the  ounce. 

A  similar  condition  to  this  often  results  in  children 
from  infection  by  pustular  eczema,  conveyed  by  the  fingers 
or  extending  from  the  head.  This  is  best  treated  by 
dilute  white  precipitate  ointment,  after  removing  the 
crusts  with  warm  sweet  oil. 

Fupuneles. — The  occurrence  of  small  boils  in  the 
skin  of  the  meatus,  due  to  inflammation  of  sebaceous 
follicles,  leads  to  the  development  of  acute  pain,  while 
the  sweUing  may  close  the  lumen.  The  usual  site  is  just 
inside  the  meatus,  on  the  anterior  or  posterior  wall.  The 
deeper  it  is  situated  the  greater  the  amount  of  pain.  As 
in  other  diseases  of  the  meatus,  the  pain  is  increased  by 
movements  of  the  jaw  or  pressure  on  the  ear.  Not  un- 
commonly one  such  boil  succeeds  another  from  auto- 
infection.  With  discharge  of  the  contents,  the  pain  and 
swelling  subside.    For  immediate  relief  a  hot  fomentation 


Cerumen  1 8 1 

should  be  appKed  over  the  ear  and  the  side  of  the  head, 
while  a  hot  concentrated  solution  of  boracic  acid  in  alcohol 
should  be  instilled  in  the  ear,  or  a  plug  of  cotton-wool  may 
be  used,  soaked  in  glycerine  and  laudanum,  or  laudanum, 
tincture  of  belladonna,  and  saturated  alcohoHc  solution 
of  cocaine,  in  equal  parts.  Pus  should  be  released  by 
pricking  the  boil  as  soon  as  it  can  be  recognised,  and 
subsequent  formation  of  boils  can  be  prevented  by  the 
application  of  dilute  nitrate  of  mercury  ointment.  Opium 
may  be  required  to  procure  sleep,  and  constitutional 
treatment  is  necessary  to  restore  the  health,  or  such  drugs 
as  arsenic  or  sulphide  of  calcium  given  internally  may 
control  the  further  development  of  boils.  Perhaps  the 
most  effective  remedy  is  the  injection  of  an  antidotal 
serum  prepared  from  the  organism  present. 

Cepumen. — As  a  result  of  high  temperature,  and 
perhaps  more  often  in  elderly  people,  a  collection  of  wax 
and  epithehum  may  cause  a  hard  plug  in  the  meatus, 
which  acts  as  a  foreign  body,  producing  deafness,  pain, 
and  tinnitus,  occasionally  associated  with  vertigo  or  dry 
cough.  This  may  sometimes  be  removed  by  syringing 
with  warm  soap  and  water.  If  it  is  too  hard,  it  should 
first  be  softened  by  dropping  into  the  ear  at  night  a 
warm  solution  of  bicarbonate  of  soda  10  grains  to  the 
ounce,  or  bicarbonate  of  soda  gr.  xx,  glycerine  5  j  and 
rosewater  ^],  or  a  few  drops  of  oUve  oil  poured  in  from 
a  hot  teaspoon. 

In  India  similar  plugs  in  the  meatus  are  made  up  of  a 
vegetable  fungus  mixed  with  epithelium,  the  condition 
being  known  as  Otomycosis.  Similar  symptoms  result, 
often  accompanied  by  shght  serous  discharge.  The  treat- 
ment consists  in  frequent  syringing  with  warm  solution 
of  perchloride  of  mercury,  1  in  1000,  chlorinated  hme 
2  grains  to  the  ounce,  or  hyposulphite  of  soda  4  grains 
to  the  ounce,  followed  by  alcohol  as  an  astringent,  and 
to  dry  the  surface. 


1 82  Otorrhoea 

During  tlie  recent  epidemic  of  influenza  many  instances 
have  occurred  of  sudden  intense  pain  in  ttie  ear,  some- 
times followed  by  deafness,  which  appears  to  be  due  to 
small  haemorrhages  both  in  the  internal  ear  and  tympanic 
membrane.  As  in  other  kinds  of  earache,  pain  may  be 
allayed  by  the  instillation  of  a  solution  of  morphia  or 
laudanum,  and  a  hot  application  to  the  side  of  the  head. 
Other  preparations  that  may  be  employed  in  the  same 
way  are  simple  hot  water,  almond  oil,  10  or  20  per  cent, 
solution  of  glycerine  or  carbolic  acid  in  water,  or  a 
20  per  cent,  solution  of  cocaine.  Externally,  poppyhead 
fomentations  or  a  hot  flannel  bag  of  camomile  flowers 
are  popular  remedies. 

OtOPPhcea,  or  chronic  purulent  catarrh,  following 
middle-ear  disease,  is  commonly  associated  with  the 
exanthemata  or  naso-pharyngeal  catarrh,  especially  in 
early  life.  In  young  children  acute  otitis  may  constitute 
a  very  obscure  complaint,  giving  rise  to  high  fever  lasting 
several  days  without  any  lesion  being  apparent,  until 
discharge  occurs,  unless  the  ears  are  specially  examined. 
In  all  conditions  in  which  the  meatus  is  occluded  by 
exfoliation  or  discharge,  the  instillation  of  a  3  per  cent, 
solution  of  hydrogen  peroxide  or  mopping  out  with  ozonic 
ether  affords  a  ready  method  of  clearing  the  lumen. 

THE  NOSE 

In  connection  with  the  skin  of  the  nose  and  adjacent 
parts,  dilatation  of  capillary  veins  sometimes  produces 
spots  or  small  nsevoid  patches,  which  are  mainly  objection- 
able on  account  of  being  conspicuous.  They  are  best 
obliterated  by  the  galvanic  current  conveyed  through  a 
platinum  needle,  both  poles  being  apphed  to  the  dilated 
vessel. 

Acne  posaeea  consists  of  small  patches  of  dilated 
capillaries  about  the  nose,  this  being  a  terminal  portion 
of  the  circulation,  accompanied  in  later  stages  by  hyper- 


Lipoma  Nasi  183 

trophy  with  increased  secretion  of  the  sebaceous  follicles. 
Outbreaks  of  deep  red  spots  occur  at  intervals,  and  are 
very  disfiguring.  The  disturbance  has  been  referred  to 
indigestion,  exposure  to  weather,  and  perhaps  in  many 
cases  to  the  abuse  of  alcohol,  though  as  previously  men- 
tioned congestion  of  the  nose  may  be  associated  with 
interference  with  the  circulation,  exerted  by  tight  clothing, 
whether  of  the  neck  or  waist.  The  treatment  consists 
in  removing  any  cause  of  indigestion  or  of  embarrassment 
of  the  circulation,  and  attending  to  the  general  health. 
Locally  some  preparation  of  sulphur,  either  ointment  or 
lotion,  or  lotion  of  perchloride  of  mercury,  appears  to 
exert  some  beneficial  effect,  probably  by  controlling 
decomposition  in  the  contents  of  the  follicles.  In  severe 
cases  the  dilated  vessels  may  be  scarified,  haemorrhage 
being  restrained  by  the  use  of  perchloride  of  iron  or 
liquefied  carbolic  acid  ;  or  recourse  may  be  had  to  the 
galvanic  needle.  Only  small  areas  should  be  thus  treated 
at  one  time. 

Lipoma  nasi  is  characterised  by  the  development 
of  irregular  patches  at  the  tip  and  alae  of  the  nose,  often  of 
a  purple  colour.  It  occurs  in  elderly  men  and  is  usually 
attributed  to  alcoholism.  The  protuberance  is  due  to 
a  general  hypertrophy  of  the  skin,  subcutaneous  tissue, 
and  sebaceous  follicles,  and  not  to  adipose  tissue  alone. 
Treatment  consists  in  discontinuing  the  use  of  alcohol, 
and  shaving  off  the  thickened  skin,  leaving  the  deeper 
layers  with  portions  of  the  glands,  from  which  renewal 
of  epithelium  spreads  over  the  raw  surface.  During  this 
process  protection  should  be  afforded  by  a  simple  oint- 
ment, as  in  skin-grafting. 

The  interior  of  the  nostrils,  except  for  superficial  dis- 
turbance of  the  mucous  membrane,  is  generally  the 
province  of  the  surgeon. 

In  hot  dry  weather  either  irritation  or  soreness  may 
result  from  desiccation   and  the  inhalation  of  irritating 


1 84  Ozaena 

or  septic  dust.  This  may  be  relieved  by  introducing 
into  the  nostril,  with  the  little  finger,  glycerine  and 
water,  or  hazeline  ointment. 

Hyperaemia  and  swelling  of  the  mucous  membrane, 
with  partial  obstruction  of  nasal  breathing,  may  be 
remedied  by  a  spray  of  adrenalin  solution  1  to  1000, 
directed  into  the  nostril,  or  by  sniffing  the  vapour  of 
menthol  and  camphor,  using  the  solution  given  on  p.  98. 
This  local  ansesthetic  is  also  of  value  in  suppressing  the 
continued  and  violent  attacks  of  sneezing  from  which 
some  individuals  suffer,  apart  from  catarrh.  These 
vaso-motor  disturbances  are  specially  prominent  in  the 
condition  known  as  hay-fever,  associated  with  inhalation 
of  grass  pollen  during  the  early  weeks  of  summer,  ac- 
companied by  sneezing  and  lachrymation.  If  the  patient 
is  unable  to  avoid  the  surroundings  in  which  the  attacks 
are  set  up,  relief  may  be  obtained  by  spraying  or  paint- 
ing the  interior  of  the  nares  with  a  solution  containing 
2  grains  of  cocaine  to  2  drachms  of  1-1000  adrenalin 
solution.  This  application  needs  repetition  at  intervals 
of  three  or  four  hours,  and  is  a  valuable  local  anaesthetic, 

OzSBna. — This  term  has  been  comprehensively  ap- 
phed  to  foul-smelling  discharge  from  the  nose,  usually 
not  apparent  to  the  patient.  It  covers  a  very  large 
number  of  local  conditions,  such  as  atrophic  nasal 
catarrh,  caries,  and  necrosis  of  the  bone,  tuberculosis, 
and  other  affections  of  the  mucous  membrane,  the 
presence  of  foreign  bodies  and  rhinoliths,  as  well  as 
purulent  affections  of  the  accessory  sinuses,  and  some 
forms  of  new  growth  which  require  careful  investigation 
and  independent  treatment. 

Chronic  or  hypeptpophie  rhinitis  most  commonly 
occurs  in  children,  associated  with  repeated  attacks  of 
ordinary  catarrh,  adenoid  vegetations  in  the  vault  of 
the  pharynx,  enlarged  tonsils  or  obstruction  of  the  nares 
from  any  caus^.     In  the  early  stage  the  disease  is  char- 


Treatment  185 

acterised  by  continuous  thin  mucous  or  muco-purulent 
discharge,  with  congestion  of  the  mucous  membrane. 
If  untreated  the  mucous  membrane  becomes  thickened 
by  swelhng  and  congestion,  especially  over  the  turbinate 
bones,  and  finally  by  hypertrophy,  infiltration  with  in- 
flammatory material,  and  increased  size  and  activity  of 
the  glands.  The  symptoms  which  ensue  are  blocking  of 
the  nose  with  frequent  need  to  clear  it,  a  nasal  tone 
of  voice,  a  vacant  expression  due  to  mouth-breathing, 
and  sometimes  deafness  from  extension  to  the  orifice 
of  the  Eustachian  tube. 

Reflex  disturbances  may  occur  in  the  respiratory 
system.  Posterior  rhinoscopic  examination  discloses 
granular  pharyngitis,  with  over-growth  of  gland  tissue 
in  the  vault  of  the  pharynx  and  bulging  of  the  posterior 
extremities  of  the  turbinate  mass  in  the  region  of  the 
posterior  nares. 

In  atpophie  Phinitis,  sometimes  referred  to  as 
dry  or  foetid  catarrh,  or  ozsena,  the  changes  are  rather  in 
the  opposite  direction  of  shrinking  and  atrophy  of  the 
mucous  membrane  and  glands.  The  nasal  cavities 
appear  unusually  large,  the  membrane  being  paler  than 
natural,  and  covered  with  yellowish  green  adherent 
crusts,  decomposition  in  these  supplying  the  foetor  which 
is  generally  present. 

Treatment  in  both  instances  must  be  directed  to  the 
general  health.  A  tonic  regimen,  with  cod-liver  oil 
and  maltine,  or  the  iodide  or  phosphate  of  iron  in  the 
form  of  syrup,  should  be  prescribed.  Provided  the 
nostrils  are  not  occluded  a  nasal  douche  should  be  used, 
one  of  the  best  solutions  being  that  known  as  Dobefl's, 
mentioned  on  p.  100,  or  a  saturated  watery  solu- 
tion of  acetozone,  or  a  3  per  cent,  solution  of  peroxide 
of  hydrogen.  In  some  cases  it  may  be  necessary  to 
dislodge  some  of  the  crusts  with  the  aid  of  the  speculum 
beforehand.     Failing  the  use  of  the  douche,  a  solution 


1 86  Balanitis 

may  be  employed  in  spray,  sucli  as  the  mixture  men- 
tioned on  p.  98,  diluted  if  necessary  with  liquid 
petroleum,  or  a  solution  of  thymol  gr.  x  to  an  ounce 
of  the  same  medium.  Tannic  acid,  sulphocarbolate, 
and  iodide  of  zinc  in  solutions  of  the  same  strength  in 
water  are  also  used. 

The  advanced  stages,  more  particularly  of  the  hyper- 
trophic form,  demand  the  surgeon's  interference  in  order 
to  remove  obstructing  masses  and  clear  the  passage. 

In  the  atrophic  form  crusts  should  be  removed  by 
softening  them  with  boric  ointment  overnight,  and 
washing  out  the  nares  with  bicarbonate  of  soda  solution 
5-20  grains  to  the  ounce  of  water,  or  one  of  the  collunaria 
described  on  p.  100. 

Small  furuncles  not  infrequently  occur  in  the  ala 
nasi  either  just  within  or  outside  the  nostril,  and  are 
very  painful.  They  result  from  the  irritation  of  dust, 
and  no  doubt  also  from  scratching  with  the  finger-nail. 
Their  treatment  is  much  the  same  as  that  recommended 
in  connection  with  the  external  auditory  meatus. 

Epistaxis  is  mentioned  in  the  chapter  on  the 
Circulatory  System. 

GENITO^URINARY  SYSTEM 

Balanitis. — Accumulation  and  decomposition  of 
secretion  under  the  prepuce  result,  particularly  in  hot 
weather,  from  neglect  in  the  matter  of  soap  and  water, 
and  in  cases  of  phimosis  from  inability  to  properly  expose 
the  fold  behind  the  glans.  This  leads  to  irritation,  and 
later  to  actual  soreness  from  the  development  of  fatty 
acids  and  bacteria — sometimes  associated  with  inflam- 
matory oedema  of  the  skin  and  pus-liktj  discharge.  It 
is  easily  remedied  by  cleanliness,  and  should  not  be 
allowed  to  occur.  One  point  of  interest  Hes  in  the 
close  resemblance  of  the  Smegma   bacillus   to   that   of 


VuIvO'Vaginitis  187 

tubercle  in  general  appearance  and  staining  properties, 
as  well  as,  to  some  extent,  in  resistance  to  acids,  which 
has  led  now  and  then  to  suspicion  of  tuberculosis  in 
the  genito-urinary  tract  when  it  has  been  discovered  in 
the  urine.  Adequate  decolorisation  by  acid  in  preparing 
slides  should  prevent  this  mistake,  as  the  Smegma 
bacillus  does  not  retain  the  fuchsin  stain  as  completely 
as  the  tubercle  bacillus  when  so  treated. 

In  the  female  similar  conditions  may  prevail  as 
regards  the  vulva  under  hke  circumstances  of  neglect, 
and  the  baciUi  are  then  to  be  met  with  in  greater  quantity 
in  the  urine.  Owing  to  the  admixture  of  other  local 
discharges,  the  discovery  of  pus  albumen,  blood,  or 
organised  deposits  in  the  urine  of  females  may  often 
be  discounted  unless  the  specimen  has  been  obtained  by 
the  use  of  the  catheter. 

Vulvo-vaginitis  in  little  girls  may  in  some  measure 
be  regarded  as  the  counterpart  of  the  preceding,  being 
commonly  the  result  of  dirt  and  neglect,  and  associated 
septic  infection,  but  owing  to  the  wider  scope  for  extension 
and  greater  inaccessibility  of  the  passages,  it  is  a  very 
much  more  serious  and  protracted  matter  from  the 
point  of  view  of  treatment.  Added  to  this,  the  HabiHty 
of  infection  to  be  conveyed  not  only  to  the  patient's 
eyes,  but  to  others,  renders  the  most  stringent  pre- 
cautions necessary  in  order  to  limit  the  disease  as  well 
as  to  cure  it.  One  of  the  first  things  the  practitioner 
has  to  do  is  to  combat  the  idea  of  specific  infection, 
which  is  often  advanced  and  can  be  estabhshed  only 
in  very  rare  cases  by  other  evidence  than  that  of  the 
presence  of  diplococci  in  the  secretion,  the  gonococcus 
being  by  no   means  a  distinctive  organism. 

The  important  points  in  the  case  of  this  affection 
are  isolation,  absolute  cleanliness,  the  removal  of  any 
ascertainable  sources  of  irritation,  and  the  free  use  of 
antiseptic  or  astringent  lotions,  such  as  perchloride  of 


1 8  8  Enuresis 

mercury   (1-2000),   boracic    acid    4    per  cent.,  sulphate 
of  zinc  or  alum  5  grains  to   the  ounce,  or   as  the  Lotio 


Sulphatum — 

^.  Zinci  Sulphatis 

,        .    gr.  XXX 

Aluminis          .         , 

,        .     gr.  XXX 

Ferri  Sulphatis 

gr.  XX 

Cnpri  Sulphatis 

gr.  ij 

Aquam  ad. 

.    ad  §  vlij 

This  may  need  some  further  diluting,  as  it  contains 
about  10  grains  of  salts  to  the  ounce. 

Discharge  should  be  first  washed  away  with  warm 
water,  and  the  superficial  parts  afterwards  dusted  with 
iodoform.  The  apphcations  should  be  made  at  the 
body  temperature  by  means  of  an  irrigator,  the  labia 
being  held  well  apart. 

Aphthous  Vulvitis  causing  superficial  ulceration 
with  accumulation  of  fungus,  epithelium  and  dried  blood 
on  the  labia  requires  similar  treatment.  Both  con- 
ditions call  for  tonics  and  a  Hberal  regimen. 

Enuresis. — Nocturnal  incontinence  of  urine  is  not 
uncommon  in  both  sexes,  though  more  frequent  in 
males,  up  to  the  age  of  puberty,  and  may  be  connected 
with  defective  nursery  instruction,  as  it  usually  yields 
to  disciplinary  measures. 

Lack  of  control  over  the  bladder  is  so  general  in 
infants  that  it  sometimes  continues  unnoticed  later  into 
childhood  than  is  reasonable,  so  that  complaint  is  not 
usually  made  till  some  occasion  arises  for  the  child  to 
leave  home,  either  to  go  to  school  or  perhaps  to  a  con- 
valescent institution. 

The  condition  under  consideration  must  be  regarded 
as  a  habit  and  not  the  occasional  effect  of  the  irritation 
caused  by  threadworms,  long  prepuce  or  calculus  or 
growth  in  the  bladder,  or  even  the  loss  of  control  which 
may  accompany  or  follow  an  acute  illness,  though  these 
causes  should  be  borne  in  mind  and  carefully  excluded. 


Dysuria  189 

Habitual  incontinence  runs  on  from  infancy  and  is 
scarcely  ever  interrupted  by  a  definite  interval. 

The  most  efficient  remedy  consists  in  waking  the 
child  at  intervals  to  pass  water — at  first  every  three 
hours,  then  every  four,  gradually  lengthening  the 
interval  till  the  whole  night  can  be  passed  without 
disturbance.  After  six  or  seven  years  of  age  a  week  of 
such  treatment  is  usually  sufficient.  Tonics,  cold  baths, 
and  the  administration  of  belladonna  increased  till  its 
physiological  effects  appear  may  expedite  matters. 
Tinctura  Lycopodii  Tr|_xv-lx  and  Antipyrin  gr.  v-x 
have  been  given  with  the  same  object.  A  practical 
expedient  is  to  fasten  an  empty  cotton  reel  by  means 
of  a  tape  over  the  lumbar  spine,  so  as  to  prevent  dorsal 
decubitus,  as  it  is  in  this  position  that  the  accident 
usually  occurs.  The  application  of  a  faradic  or  galvanic 
current,  the  poles  being  placed  over  the  upper  lumbar 
region  and  the  perineum,  has  been  made  with  good  effect. 
In  obstinate  cases.  Sir  Henry  Thompson  recommended 
the  application  of  silver  nitrate  solution  (gr,  x  ad  5J) 
to  the  neck  of  the  bladder.  Some  benefit  may  be  as- 
sociated with  restraint  in  taking  fluid  for  two  or  three 
hours  before  bedtime. 

Dysupia. — Undue  frequency  and  urgency  in  the 
call  for  micturition  are  associated  not  only  with  con- 
ditions in  which  there  is  actual  polyuria,  but  with  states 
of  the  bladder  and  urine  which  are  not  necessarily  patho- 
logical. At  the  end  of  the  summer,  or  still  more  after 
residence  in  a  hot  climate,  the  bladder  has  become  so 
unused  to  distension  that  discomfort  occurs  when  the  con- 
tents perhaps  do  not  exceed  six  ounces,  this  intolerance 
passing  off  in  a  few  weeks  or  days,  especially  if  it  is  not 
too  readily  indulged.  Marked  acidity  or  alkalinity  of 
the  secretion  likewise  causes  irritation,  and  may  vary 
with  the  time  of  day  and  character  of  the  food.  In 
many  instances  of  strongly  acid  urine  a  deposit  of  uric 


1 9^  Haematuf  ia 

acid  or  oxalate  of  lime  takes  place  which  may  supply 
an  additional  indication  to  that  afforded  by  the  rapid 
and  intense  change  produced  on  litmus  paper. 

The  exhibition  of  alkaHs  and  a  preponderance  of 
vegetable  food  will  generally  correct  this  abnormality. 

The  opposite  condition  of  over-alkahnity,  excluding 
ammoniacal  urine  which  is  generally  associated  with 
chronic  cystitis,  usually  accompanies  acid  dyspepsia, 
the  urine  being  alkahne  in  proportion  as  the  gastric 
contents  are  acid.  This  state  is  often  associated  with 
separation  of  phosphates,  either  as  a  white  precipitate 
rendering  the  urine  cloudy  when  passed,  or  appearing 
as  an  iridescent  pellicle  on  the  surface  after  standing. 
In  either  case  tricalcic  phosphate  is  the  material  separated. 

It  may  be  owing  to  the  absence  of  muscular  exertion 
in  the  early  hours  of  the  day,  or  the  preponderance  of 
vegetable  food  in  the  first  meal,  that  this  alkaHnity  of 
the  urine  and  associated  frequency  of  micturition  are 
most  marked  before  noon. 

Frequent  micturition  from  this  cause  may  be  remedied 
by  increased  animal  food,  and  the  administration  of 
benzoate  of  ammonia  in  10-grain  doses.  Irritation  due  to 
over-concentration  of  the  urine  may  be  corrected  by  an 
increase  of  fluid.  The  presence  of  some  unusual  con- 
stituent in  the  urine  derived  from  the  food  or  faulty 
metabolism  has  a  similar  effect,  depending  perhaps  on 
idiosyncrasy — such  articles  of  diet  as  tea,  champagne, 
and  asparagus  may  be  mentioned,  and  the  effect  of 
glycosuria  apart  from  polyuria. 

In  all  cases  of  frequent  micturition,  tincture  of  hyos- 
cyamus,  the  bromides,  dilute  hydrocyanic  acid,  and 
infusion  of  buchu  have  a  sedative  effect.  There  is  a 
nervous  element  in  most,  and  some  may  be  regarded 
as  entirely  neurotic. 

HaBmatupia. — The  causes  of  this  occurrence  are 
manifold   and   usually   serious,   but   there   is   one   form 


Menstruation  191 

occasionally  met  with  in  children  which  is  of  little  account 
and  may  easily  be  avoided.  This  is  hsematuria  usually 
occurring  in  the  spring,  and  associated  with  eating 
rhubarb.  A  sufficient  number  of  cases  have  appeared 
annually  in  the  early  months  of  the  year  to  render  this 
matter  quite  certain.  The  attacks  come  on  unexpectedly 
in  otherwise  healthy  individuals,  and  naturally  give  rise 
to  some  alarm  ;  but  quickly  subside  and  are  not  accom- 
panied by  any  serious  symptoms.  The  blood,  which 
is  generally  abundant  enough  to  render  the  urine  quite 
red,  is  accompanied  by  crystals  of  oxalate  of  lime  derived 
from  the  rhubarb,  but  there  is  no  albumen  beyond 
what  may  be  attributed  to  the  blood  itself. 

Menstpuation  is  often  attended  both  by  pain  and 
temporary  change  in  disposition,  which  may  be  more 
marked  in  some  individuals  and  on  some  occasions,  and 
may  even  be  attended  by  syncopal  attacks. 

At  these  times  it  is  very  important  to  avoid  chill  and 
over-fatigue,  and  it  need  hardly  be  said  that  any  device 
to  arrest  or  postpone  the  natural  process,  sometimes 
attempted  in  view  of  particular  engagements,  is  to  be 
seriously  deprecated.  Relief  from  pain  is  generally 
obtained  by  lying  down  or  raising  the  feet  to  a  level 
with  the  body,  and  such  drugs  as  ammonol  or  chloretone 
in  5-grain  doses  will  relieve  minor  pain  and  discomfort, 
but  the  treatment  of  severe  dysmenorrhoea  is  a  more 
serious  matter.  The  use  of  opiates  is  especially  to  be 
avoided. 

Towards  the  cessation  of  the  menstrual  periods  at 
about  fifty  years  of  age,  various  peculiar  symptoms — 
psychical  changes  and  neuroses — are  prone  to  develop, 
and  may  give  rise  to  much  speculation  and  perplexity 
in  diagnosis  unless  this  climacteric  state  is  recognised. 
Syncopal  attacks,  vertigo,  headache,  mental  depression 
or  excitement,  and  variorus  vaso-motor  phenomena,  such 
as  flushing,  tingling,  pins  and  needles,  or  sensations  of 


192  Infants 

cold  patches  and  nervous  shivering  occur.  The  psychical 
changes  may  be  very  marked  so  as  to  call  for  seclusion, 
constant  companionship,  or  even  removal  to  an  asylum, 
but  these  more  serious  developments  are,  fortunately, 
comparatively  rare,  and  the  minor  ones  are  intermittent. 
A  socially  quiet  life  for  a  time  and  the  bromides,  with 
valerian  or  asafetida,  ichthyol  5  grains  in  pU.  or  other 
anti-spasmodics,  may  be  of  some  use  occasionally. 

INFANTS 

At  the  time  of  birth  the  anatomy  of  the  child  is  not 
absolutely  complete,  and  in  many  instances  the  estab- 
lishment of  function  is  delayed  for  some  weeks.  The 
average  height  is  just  under  twenty  inches,  the  increase 
for  the  first  year  being  eight,  and  for  subsequent  years 
about  three  inches,  so  that  the  height  is  about  doubled 
in  six  years,  and  by  fourteen  growth  has  reached  com- 
pletion to  within  one-twelfth  of  the  full  stature.  The 
average  weight  of  the  infant  at  birth  is  7  lb.  There 
is  commonly  a  slight  loss  of  weight  during  the  first  week 
of  Hfe,  and  then  a  steady  increase  amounting  to  about 
6  ounces  a  week  in  the  first  three  months,  5  ounces  in 
the  second  three  months,  and  3  ounces  a  week  for  the 
remainder  of  the  first  year.  Variations  occur  very 
readily  in  connection  with  slight  disturbances,  but  the 
average  is  usually  made  up  when  one  day  is  compared 
with  another.  Both  temperature  and  pulse-rate  are 
higher  in  infants  than  in  adults,  the  normal  temperature 
being  99°  and  the  pulse-rate  declining  from  130  to  140 
at  birth  to  100  at  the  end  of  the  fifth  year.  At  first  the 
special  senses  are  undeveloped,  objects  and  sounds  not 
being  distinguished  till  the  child  is  a  week  or  two  old. 
The  lachrymal  secretion  does  not  appear  till  about  the 
second  month,  and  the  secretion  of  the  skin  about  the 
same   time.     Perhaps   more  important  is   the   delay  in 


Post«'NataI  Development  193 

functional  activity  of  the  salivary  glands  and  pancreas. 
Saliva  is  only  sufficient  to  moisten  the  mouth  until 
about  the  fourth  month,  but  it  does  not  exert  any 
amylolytic  effects  until  towards  the  end  of  the  sixth  to 
the  ninth  month,  and  it  may  be  assumed  that  the  same 
is  true  of  the  pancreas,  so  that  starchy  materials  cannot 
be  digested  before  this.  Deficiency  of  bile  acids  in  the 
early  months  is  sufficient  to  account  for  the  incomplete 
assimilation  of  fats  in  excess.  The  stomach  at  birth 
has  a  capacity  of  1  to  2  fluid  ounces,  doubled  by  the  end 
of  the  first  month  and  reaching  10  ounces  at  the  end  of 
the  first  year. 

The  infant  is  usually  able  to  hold  up  his  head  after 
two  months,  to  sit  up  after  seven  months,  and  stand  at 
twelve  months.  Attempts  to  hasten  these  muscular 
efforts  may  result  in  spinal  curvature  or  flat  foot,  the 
muscular  and  ligamentous  structures  not  being  adapted 
to  sustain  the  weight  of  the  body  at  an  earlier  period. 
At  the  end  of  the  sixth  month  the  teeth  begin  to  appear, 
and  it  is  about  this  time  that  dribbling  of  saliva  is  most 
apt  to  occur.  Their  appearance  may  be  attended  with 
febrile  attacks,  irritability,  disturbances  of  digestion, 
and  sometimes  skin  eruptions,  or  even  convulsions,  but 
these  must  not  be  hastily  attributed  to  teething.  These 
symptoms  are  usually  met  by  laxatives  and  small  doses 
of  bromide  of  potassium.  Only  very  occasionally, 
where  there  are  great  vascularity  and  tension  in  the  gums, 
should  recourse  be  had  to  scarification.  This  may 
afford  relief  by  diminishing  hypersemia,  but  it  is  very 
questionable  if  it  facilitates  eruption  of  teeth. 

Perhaps  the  earliest  abnormality  noticed  immediately 
after  birth  is  the  misshapen  appearance  of  the  head, 
called  caput  succedaneum.  It  is  a  form  of  local  oedema, 
with  congestion  and  some  blood  extravasation  in  the 
scalp,  which  disappears  of  itself  within  twenty-four  hours. 
Distinct  from  this  is  the  indented  appearance  due  to 


194  Icterus  Neonatorum 

cephalhsematoma,  the  external  form  of  which  usually 
develops  just  after  birth,  and  is  distinguished  by  the 
presence  of  a  raised  ring  at  the  circumference,  though  it 
may  be  elastic  and  fluctuating  at  first.  The  condition 
calls  for  no  treatment,  and  subsides  of  itself  in  the  course 
of  a  few  weeks. 

Stomatitis,  whether  catarrhal  or  aphthous,  is 
generally  benefited  by  small  doses  of  rhubarb  and  soda, 
and  the  local  application  of  the  glycerine  of  borax. 
Symmetrical  superficial  ulcers  over  the  hard  palate, 
described  as  Bednar's  Aphthae,  may  be  touched  with 
a  solution  of  permanganate  of  potash  5  grains  to  the 
ounce,  or  boric  acid  15  grains  to  the  ounce,  or  with 
lapis  divinis  composed  of  equal  parts  of  sulphate  of 
copper,  alum,  and  saltpetre  fused  together.  In  the 
parasitic  form  of  stomatitis  known  as  thrush,  occurring 
in  weakly  infants,  the  whitish  patches  should  be  painted 
with  a  solution  of  sulphate  of  copper  or  carbolic  acid 
2  grains  to  the  ounce  of  water. 

Icterus  Neonatopum. — This  general  yellow 
staining  of  the  skin  usually  appears  about  the  second  day 
after  birth,  and  lasts  about  a  fortnight.  The  skin  seems  to 
be  chiefly  affected,  and  there  are  no  evidences  in  the  con- 
junctiva or  secretions,  nor  are  there  any  symptoms,  but 
while  it  lasts  there  may  be  some  check  to  nutrition  and 
growth.  It  is  stiU  doubtful  whether  there  is  any  local 
disturbance  in  the  liver,  or  whether  it  may  not  be  due 
entirely  to  blood  changes  in  the  skin.  Beyond  bathing 
no  treatment  is  called  for,  and  the  practice  of  adminis- 
tering calomel  is  of  very  doubtful  value. 

Epythema  neonatOPum  is  characterised  by  deep 
redness  of  the  skin  soon  after  birth,  which  may  be  associ- 
ated later  with  some  desquamation.  The  treatment  consists 
in  avoiding  irritation  by  soap,  employing  oatmeal  water 
instead,  and  the  subsequent  application  of  a  dusting 
powder  of  zinc  oxide  1  ounce,  powdered  starch  4  ounces. 


Diarrhoea  195 

Vomiting"  in  infants  is  usually  associated  with  over- 
feeding or  the  administration  of  unsuitable  food.  The 
best  treatment  consists  in  diminishing  the  amount  or 
altering  the  constitution  of  the  diet,  usually  in  the  direc- 
tion of  making  it  more  dilute  and  more  alkaline,  and  in- 
creasing the  intervals  between  meals.  If  diluted  milk 
or  whey  is  rejected  it  may  be  necessary  for  a  few  days  to 
substitute  veal  broth,  or  albumen  water  consisting  of  the 
white  of  four  eggs  to  the  pint  of  water  sweetened  with 
cane  sugar  or  lactose. 

Diapphcea  commonly  occurs  in  children  and  infants 
from  irritation  or  fermentation  in  connection  with  negli- 
gence in  diet.  Suckling  infants  may  develop  looseness 
of  the  bowels  from  the  colostrum,  or  other  features  of 
the  milk  dependent  on  emotional  disturbance,  or  from 
variation  in  health  or  in  food  on  the  part  of  the  mother ; 
while  those  fed  artificially  are  liable  to  suffer  in  conse- 
quence of  lack  of  cleanliness  in  connection  with  feeding 
bottles  or  unsuitable  food.  The  stools,  besides  being 
more  liquid  and  numerous  than  normal,  are  usually  green 
in  colour,  offensive,  acid  in  reaction,  frothy,  and  contain 
much  undigested  curd.  There  is  excoriation  of  the  nates, 
increased  peristalsis  with  abdominal  distension,  attended 
by  pain  and  restlessness.  The  tongue  is  furred,  desire 
for  food  capricious,  and  wasting  is  obvious  in  a  day  or 
two.  If  the  attack  does  not  quickly  subside  there  may 
ensue  a  chronic  catarrh  or  dysenteric  form  of  diarrhoea, 
with  emaciation.  The  countenance  becomes  drawn,  the 
eyes  sunken,  cyanosis  or  convulsions  occur  in  bad  cases, 
and  in  such  death  not  infrequently  ensues. 

Treatment. — Mild  cases  may  be  relieved  by  partial 
starvation  and  a  laxative  dose  of  carbonate  of  magnesia 
gr.  V  or 

^  Pulv.  Rhei  ,  ,  ,  gr.  iij 
Sodffi  Bic.  ...  gr.  jss 
P.  Zingib.        ,        ,        ,        gr.  ss 


196  Constipation 

Desiccated  milk  such  as  Horlick's,  barley-water,  arrow- 
root-water and  whey  (2  ounces  of  either  with  a  small 
teaspoonful  of  white  sugar),  barley-water  10  ounces, 
white  of  egg  5  ss,  white  sugar  5  j  or  veal  broth  may  be  given 
in  quantities  suitable  to  age,  instead  of  milk,  when  curds 
appear  in  the  motions.  For  the  first  day  castor  oil 
emulsion  or  fractional  doses  of  calomel  should  be  given 
every  two  hours  to  clear  away  the  irritating  intestinal 
contents,  and  when  the  stools  approach  the  normal  in 
number  and  appearance,  a  sedative  mixture  such  as 


^  Sodii  Bicarb.   . 

gr.  ij 

Bismuth.  Garb.         ,         , 

.      gr.  jss 

Pulv.  Tragac.  co. 

gr.  j 

Sp.  Chloroformi 

ttl     S3 

Aq.  Cinnamomi 

.        .      ad3i 

may  be  given  every  four  hours. 

Bismuth  subgallate  gr.  ii-v  may  be  substituted  in 
this  mixture  if  diarrhoea  continues.  Among  domestic 
remedies  a  small  quantity  (5  j)  of  brandy,  or  a  teaspoonful 
of  raw  arrowroot  is  often  effective. 

Constipation  is  not  uncommon  in  quite  young 
infants  and  sometimes  depends  on  absence  of  peristalsis 
in  the  colon.  This  may  be  excited  by  abdominal  massage 
or  by  introducing  the  tip  of  the  little  finger,  a  glycerine 
suppository,  or  a  small  piece  of  white  soap  into  the  anus. 
More  often  a  general  laxative  may  be  required,  such  as 
a  teaspoonful  of  ohve  oil  or  a  small  piece  of  mannite ; 
the  latter  may  be  given  in  the  milk  of  artificially  fed 
infants.  In  those  who  are  being  suckled  it  is  often  best 
to  give  some  laxative  to  the  mother,  such  as  stewed  fruit, 
confection  of  senna,  or  cascara,  which  affects  the  infant 
indirectly  through  the  milk.  In  artificially  fed  infants 
it  is  most  important  to  revise  the  diet,  in  the  direction  of 
diminishing  the  quantity  of  curd,  increasing  the  fat  and 
adding  extract  of  malt,  malted  food,  or  even  oatmeal 
water  or  finely  ground  oatmeal  in  small  quantity  to  the 


Flatulence  and  Colic  197 

contents  of  tlie  bottle.  Administration  of  drugs  is  to  be 
avoided  as  far  as  possible,  but  if  other  means  fail,  small 
doses  of  magnesia  such  as  3  grains  of  the  carbonate 
or  1  or  2  drachms  of  fluid  magnesia  given  several 
times  a  day  in  the  milk  are  usually  sufficient. 

To  stimulate  the  hver  J-l  grain  doses  of  calomel,  grey 
powder,  or  Purgen  twice  a  day,  15-30  minims  of  the 
aromatic  syrup  of  cascara  or  of  the  Liquor  Euonymin  and 
pepsin,  or  syrup  of  figs  may  be  given.  In  the  case  of 
older  children  the  general  and  dietetic  rules  given  for  adults 
on  p.  28  should  be  followed,  but  in  regard  to  drugs  it 
is  often  difficult  to  continue  the  administration  of  such 
as  are  nauseous,  and  pills  are  usually  out  of  the  question, 
so  recourse  must  be  had  to  such  expedients  as  laxol,  fig 
syrup,  confection  of  senna,  cascara  chocolate,  or  Tamar 
Indien.  It  may  be  recalled  that  castor  oil  is  the  most 
satisfactory  purgative  for  continued  use,  and  when  well 
shaken  in  milk  as  small  a  dose  as  half  a  drachm  is  quite 
effective  and  almost  tasteless. 

Flatulence  and  Colie  in  infants  must  be  regarded 
as  painful  accompaniments  of  indigestion  resulting  from 
acid  fermentation,  and  should  be  met  by  antacid  and 
carminative  remedies  and  correction  in  the  mode  of 
feeding.  For  the  most  part  such  fermentation  results 
from  excess  or  too  hurried  ingestion  in  the  matter  of 
food,  which  should  be  diminished  in  quantity  or  con- 
sistence, or  be  given  at  longer  intervals. 

The  nurse's  remedy  consists  in  laying  the  infant  on 
his  stomach  across  her  knees  and  patting  his  back,  which 
may  result  in  either  eructation  or  vomiting,  with  some 
relief  to  gastric  distension.  Hot  flannels  to  the  distended 
abdomen  are  also  employed  with  some  good  effect, 
especially  when  the  gas  is  in  the  intestines.  The  most 
urgent  symptoms  may  be  relieved  by  giving  teaspoonful 
doses  of  lime  water  and  cinnamon,  dill  or  peppermint 
water  in  equal  parts,  or  grain  doses  of  carbonate  of  am- 


198  Flatulence  and  Colic 

monia  or  soda  in  these  waters,  or  soda-mint  tabloids  in 
syrup,  or  the  following  mixture  may  be  administered ; 


^.  Magnesii  Garb. . 

•        1        • 

gr.  jss 

Pulv.  Ehei 

•        •        • 

gr.i 

Syrup.  Zingib.   . 

. 

Ttl,   V 

Aq.  Menth.  Pip. 

. 

ad3j 

Every 

two  hours. 

The  soothing  of  the  child  and  reUef  of  distension  must 
first  be  considered,  but  partial  starvation  is  necessary  for 
some  hours,  and  the  resumption  of  feeding  should  be 
gradual  and  modified  in  accord  with  the  necessities  of 
the  case. 

During  the  protracted  hot  summer  of  1911  many  cases 
of  multiple  skia  abscesses  occurred  as  a  result  of  gnat 
bites  followed  by  auto-infection,  disablement  continuing 
in  some  for  several  weeks. 

A  modification  of  the  old-fashioned  method  of  cupping 
proved  remarkably  effective  in  these  and  similar  con- 
ditions. When  the  boil  had  matured,  the  contents  were 
withdrawn  by  applying  the  mouth  of  a  soda  water  bottle, 
which  had  been  heated  by  means  of  hot  water,  the  power- 
ful exhaust  accompanying  cooling  withdrawing  in  many 
instances  both  the  pus  and  central  slough  with  a  good 
deal  of  infected  serum  from  contiguous  regions,  so  that 
heahng  proceeded  rapidly,  and  the  risk  of  further  infection 
was  reduced. 

The  degree  of  suction  can  be  regulated  by  the  size 
and  temperature  of  the  bottle  which  can  be  subsequently 
detached  by  allowing  air  to  enter  under  the  hp,  or  en- 
veloping in  a  hot  wet  cloth. 


CHAPTER  VIII 
MAINTENANCE    OF    INDIVIDUAL    HEALTH 

Under  this  heading  it  is  not  intended  to  study 
valetudinarianism  in  its  morbid  aspect ;  but  merely  to 
point  out  some  common  features  in  everyday  Hfe  which 
are  either  to  be  encouraged  or  avoided,  so  as  to  steer 
clear  of  some  of  the  disorders  which  may  develop 
from  them,  as  weU  as  those  which  are  imposed  from 
without,  so  far  as  this  can  be  done  by  what  may  be 
considered  ordinary  means.  At  the  present  time  it 
is  even  considered  necessary  that  children  should  be 
taught  to  breathe,  to  walk,  and  to  vocalise,  functions 
which  it  might  be  thought  could  be  left  to  natural 
instincts.  It  is  only  in  exceptional  cases  in  which  the 
developments  of  these  instincts  are  deficient  or  are 
interfered  with  by  some  unusual  circumstance  that  such 
instrucKon  is  reaUy  required ;  but  it  is  none  the  less  evident 
that  the  proper  performance  of  these  matters  is  essential 
to  the  well-being  of  the  individual.  Numbers  of  people 
scarcely  exceed  the  ordinary  requirements  of  breathing 
and  physical  exertion  for  days  together,  losing  sight  of 
the  fact  that  the  maintenance  and  development  of  a 
reserve  power  is  a  most  important  safeguard  against  ill- 
health. 

In  regard  to  breathing,  comparative  stasis  of  the  air 
in  the  lungs  impairs  the  full  oxidation  of  the  blood,  and 
encourages  the  local  settlement  and  growth  of  micro- 
organisms, and  the  vigour  of  the  lungs  themselves.     The 

J99 


200  Respiratory  Exercise 

quality  of  the  air  breathed  has  necessarily  an  important 
bearing  on  the  general  health,  both  in  regard  to  its  vitaUs- 
ing  qualities  and  freedom  from  injurious  matter.  The 
ordinary  conditions  of  indoor  life  and  the  limitations 
imposed  by  clothing  tend  to  discourage  free  respiratory 
movement,  and  it  is  valuable  once  or  twice  a  day  to  take 
several  full  inspirations  as  part  of  the  general  routine. 
This  ensures  every  portion  of  the  lungs  being  fully  ex- 
panded, and  by  encouraging  for  a  brief  period  extra  func- 
tional activity,  helps  to  develop  the  chest,  maintain 
reserve  power,  and  prevent  the  incidence  of  pulmonary 
disease.  When  opportunity  serves,  the  reserve  power 
of  the  heart  and  lungs  should  be  exercised  and  tested  by 
such  physical  exertion  as  is  suitable  to  the  individual. 
There  is  usually  no  need  in  adolescence  to  make  special 
provision  for  this,  but  it  is  noticeable  how  very  frequently 
pulmonary  disease,  and  especially  consumption,  attacks 
young  people  at  an  age  when  the  exercises  and  games  of 
school  life  are  put  an  end  to  by  the  exactions  of  more 
serious  occupations.  It  should  therefore  be  looked  upon 
as  one  of  the  duties  of  life  to  devote  some  minutes  in 
each  day,  and  some  hours  in  each  week,  to  the  full  exercise 
of  these  important  organs.  As  age  advances,  indulgence 
in  the  violent  exercises  of  youth  is  unsuitable,  though  the 
capacity  for  them  might  well  be  prolonged,  certainly 
till  mid-life,  and  can  then  find  a  substitute  in  those  of  a 
quieter  nature.  "  Discern  of  the  coming  on  of  years,  and 
think  not  to  do  the  same  things  still,  for  age  will  not  be 
defied."  It  should,  however,  be  regarded  as  an  axiom 
that  no  exercise  is  worthy  of  the  name  which  falls  short  of 
increasing  the  rate  of  the  respiration  and  pulse,  and  pro- 
moting a  definite  action  of  the  skin.  The  value  of  exercise 
is  by  no  means  limited  to  the  development  of  heart  and 
lung  power,  but  has  an  important  influence  in  maintaining 
a  healthy  skin,  and  in  promoting  the  general  metabohsm 
by  the  functional  activity  of  the  muscles,  while  exerting 


Physical  Exercise  201 

a  similar  influence  on  the  lymphatics  as  is  accomplished 
in  a  minor  degree  by  massage.  The  enjoyment  of  fresh 
vitalising  air  is  unfortunately  not  within  the  reach  of 
every  one  under  modern  conditions  of  city  life,  but  it  is 
well  to  remember  that  it  is  at  its  freshest  before  eight  in 
the  morning,  which  is  the  most  suitable  time  for  constitu- 
tional exercise,  and  is  much  purer  during  the  night  than 
in  the  day — during  the  winter  months  at  all  events — owing 
to  the  relative  absence  of  smoke.  When  it  is  recalled 
that  the  organism  absorbs  twice  as  much  oxygen  in  a 
given  time  during  sleep  as  when  awake,  the  great  import- 
ance to  health  of  free  circulation  of  air  in  the  bedroom  is 
evident.  It  is  during  the  night  that  the  haemoglobin  of 
the  blood  is  largely  built  up,  and  during  the  period  of  rest 
of  the  tissues  oxygen  is  specially  required  to  effect  the 
complete  oxidation  and  removal  of  the  effete  product  of 
tissue  waste.  One  of  the  principal  features  in  the  main- 
tenance of  health  is  the  daily  provision  for  full  expansion 
of  the  lungs,  and  a  supply  of  the  purest  of  available  air. 
The  question  of  the  amount  and  distribution  of  sleep 
is  one  to  which  no  uniform  answer  can  be  given  as  applied 
to  all  individuals.  Some  have  worked  hard  and  long  with 
as  small  an  allowance  as  three  hours  in  the  twenty-four, 
while  others,  particularly  during  growth  and  development, 
require  twelve  or  more,  and  suffer  when  deprived  of  it. 
As  a  general  average  it  may  be  said  that  the  night  should 
be  half  as  long  as  the  day,  an  ordinary  sixteen-hour  day 
being  followed  by  an  eight-hour  night.  When  under  stress 
of  circumstances  the  period  of  activity  is  lengthened, 
say  to  twenty  hours,  it  is  more  economical  and  refreshing 
to  extend  the  rest  to  ten  hours  than  to  attempt  to  make 
up  for  deficient  sleep  by  rest  during  the  day  or  by 
working  off  the  arrears  by  degrees  on  succeeding  nights. 
It  is  as  weU  to  be  aware  of  the  fact  that  too  much 
sleep  is  almost  as  detrimental  to  health  and  vigour  as  too 
little.     On  the  one  hand,  insufficiency  leads  to  impaired 


202  Sleep 

nutrition,  with  loss  of  weight,  the  development  of  nervous 
irritability,  impaired  vigour,  and  loss  of  reserve  power, 
though  it  is  consistent,  temporarily  at  all  events,  with  in- 
creased nervous  activity,  resembling  in  this  respect  partial 
starvation,  or  at  least  restriction  of  food  below  the  usual 
limits.  The  effect  of  too  much  sleep  is  to  encourage  the 
development  of  fat,  with  increased  general  bulk,  a  decline 
in  nervous  activity,  dulness  of  the  faculties  generally, 
with  defective  power  of  attention,  impaired  memory,  and 
mental  lethargy.  It  was  an  axiom  of  Celsus  that  too 
much  should  be  varied  with  too  little,  with  a  special 
tendency  towards  too  little,  and  this  applies  to  sleep  as 
much  as  Celsus  intended  towards  food.  The  difficulty 
with  most  people  in  regard  to  sleep  is  to  get  sufficient 
on  account  of  the  distractions  of  business  and  social 
matters,  or  sometimes,  the  inability  to  sleep  when  occasion 
offers.  It  is  well  to  remember  that  excitement  of  the 
brain  towards  the  end  of  the  day  makes  sleep  difficult, 
and  the  natural  tendency  in  most  people  to  become 
drowsy  at  ten  or  eleven  o'clock  at  night  points  to  a  natural 
cycle  of  the  nervous  mechanism,  and  when  this  time  is 
passed  the  brain  becomes  active  again  and  sleep  is  more 
difficult  to  obtain  some  hours  later. 

The  first  hours  of  sleep  are  the  most  important  and 
the  most  profound,  disturbance  after  four  or  five  hours 
being  much  less  distressing  and  injurious  than  after  one 
or  two.  Circumstances  sometimes  affect  the  distribution 
of  sleep,  and  during  very  hot  weather,  as  in  the  tropics, 
it  is  often  a  good  plan  to  take  two  hours'  rest  and  sleep 
in  the  middle  of  the  day,  and  do  with  a  shorter  night, 
so  as  to  take  advantage  of  the  cooler  hours  in  the  early 
morning  ;  but  this  is  a  habit  which  needs  to  be  acquired, 
and  should  be  so  adapted  to  the  hour  of  the  mid-day  meal 
as  not  to  follow  immediately  upon  it,  but  should  succeed 
the  first  hour  of  digestion. 

The  question  of  sleeping  after  nieals  is  perhaps  not 


Sleeping  after  Meals  203 

one  that  can  be  answered  in  the  same  sense  for  all.  It  is 
generally  considered  that  to  fall  asleep,  as  most  people 
are  prone  to  do,  when  sitting  quietly  after  lunch  or  dinner 
tends  to  arrest  the  early  processes  of  digestion  and  permit 
of  fermentation  and  dilatation  of  the  stomach,  with  present 
discomfort  and  sacrifice  of  the  nutrient  value  of  the  food. 
On  the  other  hand,  there  is  a  natural  disposition  to 
h3rper8emiaof  the  digestive  system  after  taking  food,  which 
involves  relative  anaemia  of  other  parts  of  the  body,  so 
that  a  feeling  of  chilliness,  especially  in  the  extremities, 
and  disinclination  to  mental  exertion  usually  occur,  and 
elderly  people  and  invalids  commonly  sleep  after  easily 
digestible  meals  without  hurt. 

The  first  thing  that  commonly  occupies  the  attention 
in  the  morning  is  the  question  of  bathing,  and  the  tempera- 
ture of  the  bath.  It  may  be  considered  highly  salutary 
to  expose  the  skin  completely  both  to  air  and  water  at 
least  once  in  the  day,  both  as  an  exercise  to  the  cutaneous 
vessels  and  for  the  purpose  of  removing  the  secretions 
from  the  surface  and  thus  assisting  to  maintain  not  only 
the  health  of  the  skin  but  that  of  the  body  generally. 
After  the  relaxation  of  the  cutaneous  vessels  in  the  night, 
the  most  appropriate  application  is  that  of  cold  water 
rather  than  hot.  The  actual  temperature  for  most 
individuals  should  not  be  dependent  on  that  of  the  atmo- 
sphere, but  should  be  regulated  according  to  the  power 
of  reaction  of  the  circulation.  The  temperature  of  the 
cool  bath  is  from  60°  to  70°  Fahrenheit ;  below  this  it  is 
too  cold  for  many,  and  above  it  is  so  nearly  tepid  as  to 
fail  in  promoting  reaction.  Greater  cold  can  be  tolerated 
in  a  sponge  bath  than  in  one  in  which  the  body  is  entirely 
immersed.  The  duration  of  the  bath  should  be  such 
that  the  first  sharp  sensation  of  cold  has  worn  off.  The 
skin  is  then  contracted,  and  a  satisfactory  reaction  ensues, 
which  is  assisted  by  the  exercise  and  friction  of  drying. 
Orve  of  the  principal  benefits  of  the  cold  bath  as  regards 


204  The  Morning  Bath 

the  general  health  is  the  comparative  immunity  from  the 
ill-effects  of  varying  temperature  in  the  course  of  the  day 
and  a  general  increase  in  the  muscular  tone.  What  may 
be  considered  indications  for  reducing  the  degree  of  cold 
are  those  instances  in  which  blueness  of  the  surface  occurs 
and  local  anaemia,  with  numbness  and  coldness  of  the 
extremities.  These  features  indicate  that  the  degree  of 
cold  is  beyond  the  reactionary  power  of  the  individual, 
and  morning  bathing  should  either  be  given  up  or  pursued 
under  milder  conditions.  The  effect  of  some  sudden 
application  of  cold  to  the  surface  in  those  who,  from 
constitutional  reasons,  are  pre-disposed  is  often  apparently 
causative  of  sudden  seizures  of  lumbago  or  muscular 
rheumatism.  Though  this  may  prohibit  the  use  of  the 
bath  for  a  time  on  account  of  the  difficulty  of  movement, 
it  is  no  indication  for  giving  it  up,  but  rather  for  attending 
to  the  particular  condition  of  the  blood  which  is  associated 
with  the  attack.  The  most  important  adjunct  is  abund- 
ance of  fresh  air  by  free  ventilation  in  the  bath-room, 
as  the  use  of  artificial  heating,  except  for  invalids,  largely 
detracts  from  the  invigorating  effect  of  the  bath. 

For  those  who  are  unable  to  tolerate  cold  or  even 
tepid  water,  the  hot  bath,  at  a  temperature  of  90°  to  100° 
Fahrenheit,  may  be  substituted.  The  immersion  should 
be  brief,  not  more  than  five  minutes,  and  under  these 
circumstances  it  is  better  to  maintain  the  bath-room  at 
a  mean  temperature  of  60°  to  65^.  The  hot  bath  is  rather 
cleansing  than  invigorating,  and  on  account  of  the  re- 
laxation of  the  surface  vessels  which  ensues,  it  is  really 
better  taken  at  night  just  before  going  to  bed  than  the 
first  thing  in  the  morning. 

On  rising  and  retiring  it  is  a  wholesome  custom  to  drink 
half  a  pint  of  water,  either  hot  or  cold.  This  does  not 
impair  the  appetite  for  breakfast  an  hour  later,  as  does  the 
early  cup  of  tea  and  bread  and  butter,  and  it  helps  to 
make  up  the  quantity  of  fluid  necessary  during  the  day, 


Bathing  for  Pleasure  205 

a  matter  in  which  very  many  people  fall  short,  besides 
acting  as  a  natural  laxative. 

As  regards  swimming  and  bathing  for  pleasure,  this 
is  best  indulged  in  before  breakfast,  though  it  is  as  well 
to  take  a  biscuit  or  some  fruit  beforehand,  and  immersion 
should  not  be  prolonged  beyond  five  to  ten  minutes,  or 
it  will  result  rather  in  fatigue  than  refreshment.  At  other 
times,  the  precautions  to  be  observed  are  the  adjustment 
of  the  occasion  so  that  it  does  not  follow  within  two  hours 
of  an  important  meal,  and  the  avoidance  of  suddenly 
checking  natural  perspiration  by  plunging  into  cold 
water  while  overheated,  as  many  attacks  of  rheumatic 
fever  have  followed  immediately  on  this  erroneous 
practice.  The  degree  of  cold  and  duration  of  stay  in  the 
water  are  important  matters,  since  extreme  or  prolonged 
abstraction  of  heat  from  the  surface  tends  to  contract  the 
cutaneous  vessels  and  presently  those  of  the  muscles 
also,  thus  concentrating  the  blood  on  the  internal  organs 
in  what  may  be  a  dangerous  degree  of  congestion  ;  while 
putting  a  severe  strain  on  the  heart,  which  is  thus  called 
upon  to  sustain  the  effort  of  muscular  exertion  and  of 
great  increase  of  peripheral  resistance  in  the  circulation. 
It  is  probably  this  which  induces  that  dangerous  con- 
dition which  has  been  unsatisfactorily  termed  "  cramp," 
and  which  consists  in  sudden  loss  of  power  and  conscious- 
ness, from  which  the  subjects  most  rarely  recover,  even 
when  rescued  from  the  immediate  danger  of  drowning. 
The  condition  is  really  one  of  acute  cardiac  overstrain 
allied  more  nearly  to  angina  pectoris  than  to  anything  else. 

Such  attacks  are  fortunately  rare,  as  they  are  almost 
invariably  fatal,  and  it  would  be  a  pity  if  dread  of  such 
a  calamity  interfered  unnecessarily  with  a  healthy 
enjoyment.  Provided  bathers  do  not  expose  themselves 
to  undue  lowering  of  the  surface  temperature  either  by  the 
intensity  or  prolongation  of  cold,  or  to  exhaustion  from 
attempting  what  is  beyond  their  strength — for  fatigue 


2o6  Diet 

occurs  rapidly  from  exertion  in  the  water,  owing  to  con- 
tinued abstraction  of  heat  and  contraction  of  the  vessels 
in  the  muscles — bathing,  at  aU  events  in  the  summer,  can 
be  conducted  with  a  minimum  of  risk.  It  might  be  added 
that  it  is  imprudent  to  bathe  alone  or  to  attempt  a  long 
swim  when  already  fatigued.  Spare  individuals  are  more 
quickly  affected  by  immersion  in  cold  water  than  those 
with  large  muscles  or  much  fat. 

The  subject  of  occupation  before  breakfast  is  one 
which  has  been  much  debated  in  recent  years  in  regard 
to  school  life,  and  the  consensus  of  opinion  has  been 
against  any  serious  work  before  some  food  is  taken. 
Objection  cannot  be  made  to  being  out  of  doors  for  a 
short  time  in  the  early  morning,  and  this  is  never  attended 
with  the  liability  to  syncope  which  in  the  young  accom- 
panies indoor  tasks,  nor  is  there  the  same  objection  to 
physical  work  or  exercise  for  those  who  retire  early  ;  but, 
more  particularly  in  town  life,  exertion  of  any  kind  on 
an  empty  stomach  is  apt  to  be  followed  by  lassitude  before 
the  day  is  far  advanced,  and  is  quite  incompatible  with 
late  hours  and  responsible  work  during  the  day. 

The  subject  of  diet  is  too  wide  and  complex  to  treat 
of  in  detail  in  a  short  space.  The  important  feature, 
however,  which  is  often  lost  sight  of,  is  the  proper 
interval  between  meals,  which  should  be  four  or  five 
hours,  to  enable  digestion  to  be  completed  and  to  allow 
of  a  short  period  for  physiological  rest,  before  another 
is  taken.  In  the  course  of  the  day  it  is  better  that 
the  meals  should  be  characterised  by  some  prevailing 
class  of  food  than  that  they  should  be  aU  alike.  It  is 
customary,  for  instance,  to  employ  carbohydrates  prin- 
cipally for  breakfast  with  a  small  amount  of  animal  food, 
and  to  make  the  chief  meal  in  the  middle  or  at  the  end  of 
the  day  one  of  animal  food,  with  only  a  small  proportion 
of  carbohydrates.  Animal  food  generally  is  adapted  to 
growth  and  muscular  exertion,  and  to  the  resistance  of 


Diet  207 

cold.  With  the  exception  of  milk  it  is  unsuitable  for 
infants  and  quite  young  children,  but  is  particularly 
necessary  after  seven  years  until  middle  life.  As  people 
get  old  they  do  wisely  to  limit  animal  food  and  substitute 
fruit  and  vegetables,  both  for  the  sake  of  digestion  and 
to  accommodate  their  food  to  the  less  perfect  metabohsm 
of  advancing  years.  It  is  generally  admitted  that  the 
majority  of  people  take  more  food  than  is  either  necessary 
or  really  wholesome.  This  to  some  extent  merely  leads 
to  waste,  but  it  also  results  in  passing  through  the  organism 
more  dissolved  nutriment  than  the  functions  of  the  body 
call  for  or  are  perhaps  able  to  deal  with,  so  that  much  of 
the  impaired  health  depending  upon  imperfect  combustion 
of  food-matters  depends  as  much  upon  excess  of  food  as 
deficiency  of  work  and  oxygen.  Besides  a  proper  quantity 
of  food  and  proper  intervals  between  meals,  and  the 
necessary  physiological  work  and  respiratory  activity,  a 
due  amount  of  simple  fluid  is  required  to  keep  the  products 
of  tissue-change  in  proper  solution.  A  minimum  quantity 
is  two  pints  in  the  twenty-four  hours,  and  should  be  made 
up  chiefly  of  plain  water  or  weak  infusions  such  as  tea  or 
coffee.  It  is,  however,  marred  by  the  addition  of  sugar 
and  other  soluble  substances.  The  character  of  the 
food  and  amount  of  fluid  should  naturally  vary  with 
the  season  of  the  year,  the  loss  by  the  skin  in  summer 
calling  for  at  least  double  the  supply  that  is  sufficient 
in  winter. 

With  regard  to  food,  the  demands  of  cold  for  heat- 
producing  materials,  such  as  fat  and  meat,  are  greater 
in  the  winter,  but  in  the  summer  a  more  suitable  meal 
can  be  made  of  carbohydrates,  fruit  and  vegetables, 
approximating  to  the  regime  followed  in  the  tropics. 
Variation  in  diet  is  not  only  an  aid  to  appetite,  but  is 
beneficial  for  the  system,  and  changes  with  the  season 
afford  the  best  opportunity  of  obtaining  the  most  whole- 
some class  of  food  at  any  time. 


20 8  Selection  of  Food 

In  connection  with  raw  food,  there  are  certain  dangers 
which  may  be  provided  against  when  borne  in  mind. 
Salads,  and  especially  watercress,  are  liable  to  convey 
parasites,  unless  protected  during  growth  and  carefully 
washed  before  being  used.  In  the  late  summer  and 
autumn,  especially,  there  is  a  risk  of  introducing  tjrphoid 
fever  in  such  uncooked  articles  as  water,  milk,  and 
oysters,  and  even  in  partially  cooked  whitebait.  The 
risk  of  this  largely  disappears  with  the  first  frosts, 
but  during  the  months  from  July  to  the  end  of 
November  or  December  it  is  wise  to  avoid  these  things 
unless  their  source  is  unimpeachable  or  they  have  been 
submitted  to  a  sufficient  temperature  in  cooking.  Water 
should  be  boiled  for  twenty  minutes  if  required  for 
drinking,  and  may  be  freshened  by  passing  through  a 
carbon  filter  ;  but  for  the  most  part  in  London  and  most 
of  the  large  towns  the  water  supply  is  under  such  careful 
supervision  that  danger  from  this  source  is  reduced  to  a 
minimum.  This  is  not  quite  the  same  in  the  case  of 
mUk,  which  often  comes  from  great  distances  and  is 
much  mixed  and  subject  to  risks  of  indirect  infection 
by  the  local  washing  of  cans,  sometimes  with  infected 
water.  Milk  can  be  sterilised  by  heating  in  boiling  water 
for  twenty  minutes  without  being  much  altered  in  appear- 
ance or  taste  ;  it  is  then  more  easily  digested,  keeps  longer, 
and  is  freed  from  living  germs  of  disease.  This  is 
specially  important  for  children  and  invalids  who  subsist 
largely  on  a  milk  diet. 

In  regard  to  supernumerary  meals,  which  are  taken 
rather  as  a  matter  of  routine  by  invalids,  especially  those 
who  are  unable  to  digest  a  full  meal,  it  may  be  considered 
that  for  those  in  average  health  these  are  unsatisfactory, 
and  even  unwholesome.  Such  are  the  early  morning  cup 
of  tea  and  bread  and  butter,  something  at  eleven  o'clock 
in  the  morning,  and  more  commonly  afternoon  tea. 
In  many  cases  the  taking  of  small  quantities  of  food 


Supernumerary  Meals  109 

at  these  times  provokes  a  freer  secretion  of  the  gastric 
juice  than  is  requisite  for  their  digestion,  producing  the 
condition  known  as  heartburn  or  acidity,  and  in  any 
case  impairs  the  appetite  for  the  ensuing  ordinary  meal. 
There  is  not  so  much  objection  to  taking  fluids  in  the 
intervals — indeed,  the  best  time  for  this  is  about  an  hour 
in  advance  of  the  solid  food  ;  and  perhaps  the  same 
objection  should  not  be  raised  to  light  supper  in  the  case 
of  those  who  defer  retiring  to  rest  till  four  or  five  hours 
after  late  dinner,  but  in  this  case  the  nutriment  should 
be  specially  light  and  for  the  most  part  fluid,  since  the 
main  functions  of  digestion  are  in  abeyance  during  sleep 
and  an  undigested  meal  is  one  of  the  worst  enemies  to 
satisfactory  repose. 

A  brief  remark  may  be  here  made  as  to  the  danger 
of  drinking  quantities  of  cold  fluid,  particularly  when 
over-heated.  This  is  generally  accepted  and  impressed 
on  the  young,  being  associated  popularly  with  the  occur- 
rence of  colic  and  various  cutaneous  eruptions,  but  greater 
danger  lies  in  the  spasmodic  contractions  set  up,  and  I 
can  recall  at  least  one  instance  in  which  gangrene  of 
the  appendix  was  thus  induced,  involving  a  fatal  termina- 
tion within  three  days. 

Deliberation  in  connection  with  meal-times  is  most 
important.  In  the  words  of  Francis  Bacon,  "  To  be 
free-minded,  and  cheerfully  disposed  at  hours  of  meat, 
and  sleep,  and  of  exercise,  is  one  of  the  best  precepts  of 
long  lasting." 

In  regard  to  the  matter  of  clothing,  it  is  unnecessary 
and  would  be  useless  to  oppose  what  is  customary  and 
generally  found  convenient,  but  it  may  be  pointed  out 
that  a  great  number  of  people  err  in  the  direction  of 
employing  too  heavy  clothing  both  night  and  day,  and 
pf  submitting  to  unhealthy  restriction  of  natural  move- 
raent,  not  perhaps  so  much  in  the  limbs  as  in  the  thorax 
and    abdomen.     Interference    with    the    full    and    easy 

14 


2IO  Clothing 

movements  of  respiration  tends  greatly  to  limit  their 
natural  range,  and  to  impose  on  the  individual  habitually 
a  restricted  degree  of  breathing.  This  in  adolescence 
actually  impairs  the  proper  development  of  the  body,  and 
in  all  interferes  not  only  with  the  due  aeration  of  the 
blood,  but  also  with  its  easy  circulation,  for  the  respiratory 
movements  have  an  important  influence  on  the  flow  of 
blood  through  the  main  veins,  and  the  movement  of  the 
diaphragm  exerts  a  similar  influence  on  them  both  in  the 
abdomen  and  thorax.  Persistent  constriction  of  the 
waist  favours  downward  displacement  of  the  solid  organs 
in  the  upper  zone  of  the  abdomen,  and  has  an  undoubted 
effect  in  encouraging  prolapse  and  hernia  in  the  lower. 
One  important  result  of  abdominal  constriction  is  the 
development  under  violent  effort  of  inguinal  hernia, 
instances  having  frequently  occurred  in  boys  in  climbing 
or  jumping  while  wearing  a  leather  belt.  The  effect  of  a 
tight  collar  inducing  cerebral  congestion  and  headache 
has  already  been  referred  to  in  dealing  with  that  subject. 
Constriction  of  the  waist  and  lower  thorax  in  impeding 
the  circulation  is  sometimes  indicated  by  congestion  of 
terminal  vessels  in  the  nose  and  ears,  and  in  some  instances 
has  led  to  temporary  failure  of  vision,  all  which  symptoms 
have  immediately  subsided  on  releasing  the  constricted 
area.  The  amount  of  clothing  which  should  be  employed, 
whether  by  night  or  day,  should  be  just  sufficient  to 
prevent  a  sensation  of  chilliness,  and  must  be  adapted 
to  the  particular  circumstances  of  the  individual.  The 
chief  protection  is  required  when  inactive  in  the  open  air, 
as  when  driving,  and  the  least  during  active  exertion,  or 
when  sitting  in  a  warm  room.  The  difficulty  of  adapting 
oneself  to  variations  in  these  different  states  is  better 
met  by  extra  wraps  than  by  constantly  keeping  the  body 
over-thickly  clad.  It  is  generally  considered  that  loose- 
textured  fabrics,  owning  a  certain  porosity,  are  both 
healthier  and  more  comfortable  than  others.     Such    an 


Clothing  2 1 1 

impermeable  substance  as  the  ordinary  waterproof  is 
perhaps  the  worst  of  all.  The  material  which  should 
be  worn  next  the  skin  is  the  one  which  ought  to  be  most 
definitely  porous,  and  it  is  for  this  reason,  rather  than  on 
account  of  their  fibre,  that  woollen  materials  are  usually 
advocated. 

"  Wool  is  more  porous  and  more  hygroscopic  than 
vegetable  fabrics,  and  is  a  slightly  less  perfect  conductor 
of  heat.  While  it  absorbs  moisture  readily,  it  gives 
it  o£E  slowly,  so  that  far  less  cold  is  produced  by  the 
evaporation  from  a  woollen  garment  than  from  one  made 
of  vegetable  fibre.  It  conserves  the  heat  of  the  body,  and 
protects  it  from  the  heat  of  the  sun,  the  latter  property 
being  at  its  height  if  the  garment  be  white." 

"  For  work  in  a  climate  like  ours  flannel  is  the  safest 
material  to  wear  ;  if  cotton  or  linen  be  worn,  it  must  be 
loose-woven,  so  as  to  give  some  thickness  and  porosity 
to  the  fabric  "  (G.  V.  Poore). 

Any  smooth  close  material  communicates  chill  too 
readily,  and  does  not  as  a  rule  absorb  the  moisture.  On 
the  other  hand  some  people  find  flannel  too  irritating  to 
the  skin,  and  it  is  not  by  any  means  essential  to  employ 
it ;  but  whether  silk,  linen,  or  cotton  be  used,  it  should  be 
so  woven  that  the  surface  is  not  quite  smooth  and  the 
general  texture  loose,  allowing  it  to  retain  and  transmit 
air  readily.  Perhaps  the  best  alternative  is  the  Chinese 
method  of  wearing  a  net  next  the  skin  which  prevents 
complete  contact.  The  main  reason  for  advising  such 
porous  material  is  to  provide  against  the  alternation  of 
heat  and  cold,  wet  and  dry,  which  are  inseparable  from 
ordinary  climatic  conditions  and  changes  of  occupation, 
the  principal  danger  arising  from  the  rapid  cold  of  evapora- 
tion while  resting  after  exertion.  It  is  customary  to 
bring  up  the  young  to  change  into  dry  garments  when 
moist  from  exertion  or  exposure  to  wet,  and  for  the  most 
part  adults  follow  the  same  good  rule.     Many  instances 


212  Clothing 

of  lumbago  can  be  traced  to  remaining  in  damp  clothes 
after  being  over-heated,  the  chill  of  continued  evapora- 
tion being  specially  prolonged  by  the  over-lapping  of 
garments  in  the  lumbar  region. 

The  ordinary  foot  covering  is  particularly  adapted  to 
retaining  moisture ;  and  chilling  of  the  feet  in  consequence, 
as  well  as  exposure  of  the  less  protected  ankles  and 
shins  to  draughts,  which  are  more  common  near  the 
floor  than  is  generally  realised,  are  productive  of  the 
effects  of  a  lowered  blood  temperature.  Sufficient  warmth 
round  the  middle  of  the  body  is  the  most  important,  and 
many  instances  of  so-called  indigestion  are  the  result 
of  insufficient  clothing,  and  are  at  once  remedied  by  a 
flannel  belt.  Even  in  the  tropics,  more  particularly  at 
night,  as  a  protection  against  sudden  lowering  of  tempera- 
ture, such  a  flannel  binder  is  usually  worn,  the  absence 
of  it  often  leading  to  serious  attacks  of  abdominal  pains 
and  various  forms  of  inflammation.  Any  special  pro- 
tection of  this  kind  should  be  continuous,  disorder  arising 
from  intermittence  of  covering,  as  is  perhaps  best  seen  in 
connection  with  the  throat.  There  are  thosewho  advocate 
little,  and  others  who  advocate  much,  with  equal  success, 
the  incidence  of  chill  and  catarrh  being  on  those  in  the 
intermediate  class,  who  vary  one  with  the  other.  The 
natural  effect  of  warmth  is  to  dflate  the  vessels  and  an 
area  so  suffused  is  particularly  liable  to  suffer  by  sub- 
sequent exposure  to  cold. 

Speaking  generally,  the  degree  of  protection  by 
clothing  must  be  adapted  to  the  power  of  resistance  of 
the  individual  to  cold  and  the  degree  of  exposure  to 
which  he  is  liable.  Variations  in  what  is  usually  worn 
are  more  productive  of  ill-health  than  being  habitually 
too  thickly  or  too  thinly  clad. 

After  food  and  clothing  perhaps  the  next  most  im- 
portant influence  on  the  health  and  comfort  of  the  indi- 
vidual is  exercised  by  the  dwelling  and  its  suiroundings. 


The  Dwelling  213 

One  of  the  most  important  points  is  the  character  of 
the  subsoil,  preference  being  given  to  high  ground  and 
dry  porous  strata  in  which  surface  drainage  is  efficient. 
Gravel,  sand,  chalk,  and  rock  form  satisfactory  founda- 
tions for  houses.  On  the  other  hand,  clay  and  marsh- 
land are  unsuitable  owing  to  the  amount  of  water  re- 
tained in  them,  and  the  cold  damp  atmosphere  which 
usually  overlies  them.  In  towns  where  the  surface  is 
largely  covered  and  drainage  has  been  carried  on  for  years 
there  is  less  force  in  the  objection,  but  in  the  country 
and  in  suburbs  especially,  the  damp  and  cold  atmosphere 
associated  with  this  soil  favours  the  occurrence  of  catarrh 
and  rheumatism  and  is  not  conducive  to  permanent  good 
health.  The  house  itself  may  be  unsuitable  owing  to 
incomplete  ventilation  and  insufficient  exposure  to 
sunhght.  One  great  objection  to  fiats  as  compared  with 
the  ordinary  house  is  the  absence  of  a  through  current 
of  air,  the  main  direction  of  which  is  from  the  bottom  to 
the  top  of  the  house,  such  as  is  maintained  by  an  open 
staircase.  Though  it  is  usual  to  shut  up  rooms  which 
are  not  in  actual  use,  it  is  always  well  to  provide  for  a 
change  of  atmosphere  before  re-entering  a  room  which 
has  been  recently  occupied.  The  previous  history  of 
a  dwelling  also  should  be  taken  into  account,  in 
that  either  tuberculosis  or  cancer  may  be  apparently 
endemic,  especially  in  old  houses.  Instances  are  on 
record  in  which  as  many  as  four  successive  and  unrelated 
tenants  have  died  of  cancer  within  a  few  years. 

Attention  must  also  be  paid  to  the  question  of  water 
supply  not  only  from  the  point  of  view  of  purity  as  regards 
organic  matter,  but  as  to  the  amount  of  calcareous  salts 
in  solution.  The  presence  of  an  excess  of  Hme  constituting 
a  hard  water  is  sometimes  productive  of  dyspepsia,  con- 
stipation, and  even  urinary  calculus. 

The  chief  of  the  previous  considerations  have  been  in 
the   direction   of   maintaining   good  physical  health  by 


214  Water  Supply 

attention  to  the  physiology  of  the  body,  but  in  order  to 
live  happily  and  contentedly  it  is  necessary  to  consider 
the  occupations  and  amusements  of  the  mind.  A  due 
proportion  of  mental  effort  and  relaxation  is  necessary 
to  most  individuals  for  this  purpose,  the  time  being 
also  divided  between  interests  in  and  out  of  doors.  It 
is  generally  recognised  that  continuous  occupation  of 
one  kind  is  more  fatiguing  than  where  some  variety  is 
introduced,  although  the  same  number  of  hours  are 
employed.  "  The  morning  for  creation,  the  evening 
for  reading,  and  the  afternoon  for  the  work  of  the  file  " 
was  the  distribution  suggested  by  Francis  Bacon.  Varia- 
tion in  occupation  is  not  only  less  fatiguing  and  produc- 
tive of  the  best  work,  but  favours  health  by  encouraging 
a  proper  balance  of  wear  and  tear  in  the  bodily  functions. 
The  muscles  may  be  rested  while  performing  mental 
work,  and  undoubtedly  the  best  rest  from  mental  work 
is  found  in  physical  exertion. 


CHAPTER   IX 
DIET 

In  the  course  of  the  preceding  chapters  references  have 
occasionally  been  made  to  questions  of  diet,  and  it  may 
be  convenient  to  give  a  brief  account  of  this  subject. 

The  regulation  of  food  in  accordance  with  the  normal 
requirements  of  the  body  in  different  periods  of  life, 
conditions  of  climate,  and  degrees  of  activity,  as  well  as 
the  modifications  demanded  by  a  disturbed  metabolism, 
or  actual  disease,  is  a  matter  both  of  theoretical  interest 
and  practical  importance.  In  order  to  sustain  life  a 
due  amount  and  proper  proportion  of  nitrogenous,  non- 
nitrogenous,  and  inorganic  mineral  matter  are  necessary, 
and  with  these  may  well  be  considered,  in  connection 
with  ordinary  civilised  life,  the  effects  of  such  local  and 
general  stimulants  as  condiments  and  alcohol — not  that 
these  are  necessary,  but  they  are  usuaUy  introduced 
into  the  customary  dietary.  Though  the  amount  and 
proportion  of  these  principles  may  be  slightly  varied, 
under  the  conditions  already  alluded  to,  none  can  be 
altogether  dispensed  with,  and  for  the  maintenance  of 
good  health  the  consumption  of  some  part  of  the 
organic  constituents  in  a  fresh  state  is  essential.  The 
primitive  food  provided  by  nature  for  the  development 
of  the  young,  such  as  milk  and  eggs,  may  be  taken 
as  typically  complete,  containing  all  necessary  con- 
stituents, their  percentage  constitution  being  estimated 
a,s  follows ; 

»X5 


2l6 


Diet 


Gautier 


I 

luman  MUk. 

Cow's  Milk. 

Egga. 

Water  . 

86-08   . 

.     85-77     . 

.     73-67 

Albumen 

2-48  . 

.       3-04     . 

.     12-55 

Fat       . 

4-28  . 

4-04     . 

.     12-11 

Carbohydrate 

.       5-69  . 

.       403     . 

.       0-55 

Salts     . 

0-02  . 

.       0-54     . 

.       112 

Compare  with  these  the  following 


Moleschott's  diet  for 

Average  diet 

medium  work. 

in  Paris. 

Water     . 

.     7300     . 

.     80-0 

Albumen 

.       4-58     . 

.       4-1 

Fat 

.       2-96     . 

•  jl50 

Carbohydrate . 

.     14-25     . 

Salts 

1-05     . 

.       0-9 

Sandow's  training  diet,  consisting  of  about  six  pints 
of  fluid,  twenty  ounces  of  meat,  six  ounces  of  fat,  and 
twenty-eight  ounces  of  carbohydrate  food,  represents 
potential  energy  of  4,462  calories,  and  is  rather  in  excess 
of  the  average,  being  adapted  to  severe  muscular  exer- 
cise. The  previous  diets  are  calculated  in  the  dry 
state,  the  water  of  the  food  and  drink  being  tabulated 
together. 

In  actual  food  material  the  daily  diet  calculated  by 
Moleschott  for  a  man  performing  medium  physical  work 
would  be  represented  as  follows  : 

Meat 13|^   oz. 

Butter 2^     „ 

Bread 171,, 

Vegetables .  16       „ 

Sugar 2|     „ 


The  following  is  estimated  as  the  efficient  daily  diet 
for  a  man  of  150  lb.  under  different  conditions  of 
physical  activity,  reckoned  in  the  dry  state  : 


Diet  217 


Subsistence. 

Best. 

Medium 

Severe 

Very  Labori- 

"Work. 

Work. 

ous  Work. 

oz. 

oz. 

oz. 

oz. 

oz. 

Proteid     . 

.       2-32     . 

3-52     . 

4-59     . 

4-94 

.        6-50 

Fat 

.       0-84     . 

1-76     . 

2-96     . 

3-17 

.       2-85 

Carbohydrate    . 

.     11-5       . 

14-08     . 

14-26     . 

15-31 

.     20-10 

Salts          . 

.       6-5       . 

0-64     . 

1-06     . 

1-13 

1-40 

15-16  2000         22-87  24-55  30-85 

These  quantities  being  calculated  as  dry  food,  must  be 
doubled  to  give  the  actual  amounts  consumed  in  the 
moist  state.  It  will  be  noted  that  the  proteid  con- 
stituents concerned  in  the  building  up  of  the  tissues  are 
capable  of  smaller  variation  in  quantity  than  non- 
nitrogenous  constituents,  which  are  mainly  concerned 
in  the  changes  associated  with  muscle  activity.  It  is 
estimated  that  an  individual  occupied  in  brain  work 
requires  the  same  food  as  one  at  rest.  The  proportion 
of  proteid  to  carbohydrate  is  as  23  to  77 — that  is,  nitro- 
genous food  should  constitute  about  one-fourth  of  the 
non-nitrogenous  food.  The  chief  variations  which  occur 
in  the  alimentation  of  different  classes  of  society  concern 
mainly  the  consumption  of  proteid  to  a  greater  or  less 
extent  as  animal  food,  and  involve  also  difEerent  amounts 
of  animal  food  in  the  form  of  fat  instead  of  carbohydrate 
of  vegetable  origin.  It  should  be  recalled  that  the 
proteid  constituents  of  food  may  be  entirely  supplied 
either  by  meat  or  bread,  the  latter  being  cheaper  but 
more  bulky.  In  the  same  way  non-nitrogenous  con- 
stituents may  be  supplied  either  as  fat  or  carbohydrate 
with  the  same  distinction. 

"  If  the  lean  of  meat  only  were  consumed,  rather  over 
six  pounds  would  be  needed  to  furnish  the  requisite 
amount  of  carbon,  and  there  would  be  a  very  large 
surplus  of  inutilisable  nitrogen,  whilst  if  bread  only 
were  taken  the  amount  necessary  to  supply  the  necessary 
amount  of    nitrogen  would  be  rather   more  than  four 


2i8  Variations  in  Diet 

pounds,  and  this  contains  nearly  double  the  amount  of 
carbon  wanted  "  (Pavy). 

The  preponderance  of  fat  over  carbohydrate  is  in 
accord  with  the  requirements  of  a  cold  climate,  as  in  the 
habitual  diet  of  the  Eskimo,  while  a  preponderance  of 
carbohydrates  over  fat  is  better  suited  to  life  in  a  hot 
climate,  as  is  seen  in  the  usual  rice  diet  of  Hindoos,  a 
due  proportion  of  proteid  material  being  necessary  in 
either  case  to  maintain  the  structure  of  the  body.  The 
modification  in  amount  of  food  is  perhaps  best  illustrated 
by  the  starvation  diet  adopted  in  what  is  known  as 
Tufnell's  treatment  for  aneurism,  which  consists  of 
eight  ounces  each  of  fluid  and  solid,  of  which  half  is  ad- 
ministered as  the  mid-day  meal,  and  a  quarter  morning 
and  evening.     The  actual  articles  employed  are 

4  oz.  Meat. 
4     „    Bread. 
4     „    Milk. 
4     „    Claret. 

On  the  other  hand,  the  treatment  of  chronic  nervous 
diseases  and  pulmonary  tuberculosis  by  over-feeding 
involves  as  much  as  four  or  five  pounds  of  solid  food 
daily,  in  addition  to  two  pints  of  milk.  The  importance 
of  permitting  one  or  other  of  these  classes  of  food  to 
predominate  is  exemplified  in  the  treatment  of  such 
diseases  as  diabetes,  in  which  carbohydrates,  on  account 
of  their  easy  conversion  into  sugar,  must  be  entirely 
replaced  by  fat,  while  in  defective  conditions  of  the 
kidneys,  in  which  the  output  of  nitrogen  is  hindered, 
the  nitrogenous  substances  of  the  diet  must  be  cor- 
respondingly reduced. 

A  very  important  feature,  apart  from  the  nutritive 
value  of  particular  foods,  is  the  question  of  digestibility — 
that  is  to  say,  the  rapidity  and  completeness  with  which 
solution  is  effected  in  the  digestive  tract. 


Digestibility 


219 


From  Penzoldt,  Quoted  by  Gautier 

Average  Time  necessary  for  the  Stomach  to  remove  the  different 
Alimentary  Materials  which  it  digests  to  the  Intestine, 

Quantity  in  gnns.      Time  in  liours. 


A.  Waters  and  Alimentary  Drinha  : 

Pure  or  gaseous  water 

Infusion  of  weak  tea 
Coffee      . 
Coffee  with  cream 
Pure  cocoa 
Cocoa  with  milk 

Beer        .        . 

Light  wine 
Ordinary  wine 
Malaga  wine  . 
Gravy  soup     . 

B.  Flesh  of  Mammals  or  Birds 
Cooked  beefsteak,  hot  or  cold 
Roast  beef 
Roast  fillet  of  beef 
Raw  beef  (lean) 
The  same  boiled 
Raw  ham 
Cooked  ham  . 

Roast  veal,  hot  or  cold  (lean) 
Smoked  meat 
Smoked  tongue 
Sausage  of  raw  meat 
Roast  hare 

Roast  goose  moderately  fat 
Roast  duck     . 
Roast   partridge      . 
Boiled  pigeon  . 

Roast  pigeon. 
Boiled  or  roast  chicken 

C.  Other  dishes  derived  from  Animals 
Sweetbread 
Boiled  calf's  foot 
Calf's  brain     . 

Boiled  rmlk     . 


id 


ri 00-200    . 

1300-500  . 
.  200  . 
.  200  . 
.  200  . 
.  200  . 
.    200     . 

/  .  200  . 

1300  500  . 
.  200  cc, 
.  200  „ 
.  200  „ 
.  200  „ 


100 

250 
100 
250 
250 
160 
160 
100 
100 
250 
100 
250 
250 
250 
230 
230 
195 
250 


.  250 

.  250 

.  250 

(100-200 

t 300-500 


to 


2  „  3 

3  „  4 
2  „  3 

1  „  3 

2  „  3 


220 


Digestibility 


Quantity  in  grms. 

Time  in  hours. 

Soft-boUed  eggs      .... 

.    100      . 

.      1   to    2 

Hard-boiled  eggs  or  omelettes 

.    100     . 

.     2    „    3 

Gravy  soup 

.    200     . 

.     1    „    2 

D.  Fish  and  Analogous  Dishes  : 

Boiled  carp     ..... 

.    200     . 

.     2    „    3 

BoUed  pike     ..... 

.    200     . 

.     2    „    3 

Boiled   haddock      .... 

.    200     . 

.     2    „    3 

Fresh-boUed  cod     .... 

.    200     . 

.     2    „    3 

Lamprey  with  vinegar    . 

.    200     . 

.     3    „    4 

Boiled  Rhine  salmon 

.    200     . 

.     3    „    4 

Salted  or  smoked  herring 

.    200     . 

.     4    „    5 

Salted  caviare          .... 

.      72     . 

.     3    „    4 

Raw  oysters  ..... 

.      72     . 

.     2    „    3 

E.  Cooked  Vegetables  : 

Steamed  potatoes  eaten  with  salt  . 

.    150     . 

.     2    „    3 

Mashed  potatoes     .... 

.    150     . 

.     2    „    3 

Potatoes  with  vegetables 

.    150     . 

.     3    „    4 

Boiled  cauliflower  .         .         .         .         . 

.    150     . 

.     2    „    3 

Cauliflower  cooked  in  salad  . 

.    150     . 

.     2    „    3 

Cooked  asparagus  .... 

.    150     . 

.     2    „    3 

Rice  cooked  in  water     . 

.    150     . 

.     3    „    4 

Cooked  turnips       .... 

.    150     . 

.     3    „    4 

Boiled  carrots          .... 

.    150     . 

.     3    „    4 

Boiled  spinach        .... 

.    150     . 

.     3    „    4 

French  beans           .... 

.    150     . 

.     4    „    5 

Mashed  peas 

.    200     . 

.     4    „    5 

Mashed  lentils         .... 

.    150     . 

.     4    „    5 

Green  peas  cooked  in  water  . 

.    150     . 

.     4    „    5 

F.  Raw  Vegetables  : 

Cucumber  salad       .... 

.    150     . 

.     3    „    4 

Raw  radish 

.    150     . 

.     3    „    4 

G.  Bread  and  Biscuit : 

White  bread,  fresh  or  stale,  dry  or  with  te 

f  70     . 
^          {l50     . 

.  2  „  2 
.     3    „    4 

Rye  bread 

150     . 

.     3    „    4 

Albert  biscuits         .... 

f   50     . 
\150     . 

.  2  „  3 
.     3    „    4 

H.  Fruits  : 

Apples     ...... 

.    150     . 

.     3    „    4 

Raw  cherries           .... 

.    150     . 

.     2    „    3 

Stewed  cherries       .... 

.    150     . 

.     2    „    3 

Diet  in  Childhood  221 

Diet  in  Childhood. — It  will  have  been  noticed 
in  connection  with  the  analysis  of  milk  and  egg  that 
these  foods  of  the  young  contain  a  greater  proportion 
of  proteid  than  is  recommended  in  the  diet  for  adults. 
The  child  shows  greater  activity  in  metabolism  than 
the  adult,  consuming  and  breaking  up  greater  quantities, 
especially  of  proteid,  in  proportion  to  weight.  There 
is  indeed  a  gradual  diminution  in  the  output  of  nitro- 
genous waste  from  early  infancy  to  old  age,  ranging 
from  1-35  grms.  urea  per  kilogramme  at  eighteen  months 
to  "5  grm.  at  twenty-five  years  and  onwards.  Feeding 
in  infancy  and  adolescence  should  be  liberal.  Un- 
questionably the  best  method  of  nourishing  the  newly 
born  is  by  maternal  suckling.  This  should  be  carried 
on  systematically,  at  first  every  two  hours,  and  then 
every  three  hours  during  the  day,  and  twice  during  the 
night,  the  quantity  of  milk  ingested  increasing  pro- 
gressively from  80  grms.  (about  3  iij)  at  a  time  in  the  first 
month  to  150  grms.  (5  vj)  in  the  fourth.  The  duration 
of  nursing  must  depend  on  the  development  of  the  infant 
and  its  capacity  in  the  later  months  for  taking  and 
digesting  other  foods,  and  the  ability  of  the  mother  to 
continue  the  supply.  It  may  be  pointed  out  here  that 
the  enormous  mortality  of  children  from  diarrhoea 
during  hot  weather  is  closely  associated  with  artificial 
feeding,  and  there  would  be  a  great  security  for  infant 
life  if  suckling  were  continued  through  these  periods. 
Failing  this  method,  mares'  or  asses'  milk,  collected 
with  strict  antiseptic  precautions,  offers  the  closest 
approximation.  If  cow's  milk  is  employed,  as  is  most 
general,  it  should  be  mixed  with  half  its  volume  either  of 
water,  sweetened  with  5  per  cent,  of  sugar,  preferably 
lactose,  or  with  a  similar  quantity  of  decoction  of 
oatmeal  or  flour.  Of  this  mixture  one  pint  should  be 
given  daily,  gradually  increased  to  two  pints  at  the 
third  month,  which  corresponds  to  595  calories.     With 


i22  Diet  in  Childhood 

the  appearance  of  the  teeth  after  the  sixth  month, 
additions  to  the  milk  diet  should  consist  of  bread, 
flour,  yolk  of  egg,  biscuit  and  the  gravy  of  meat.  To- 
wards the  end  of  the  first  dentition,  at  about  the  second 
year,  small  quantities  of  finely  minced  meat  or  chicken, 
with  various  starchy  materials  as  puddings  and  cooked 
fruit,  should  constitute  the  diet,  avoiding  condiments, 
seasonings,  and  smoked  articles,  thus  gradually  accustom- 
ing the  child  to  ordinary  adult  food.  From  six  to  fifteen 
years  the  child  should  be  supplied  with  nearly  double  the 
amount  of  proteid  matter  in  proportion  to  his  body  weight 
as  is  required  by  the  adult.  Fats  also  ought  to  be  pro- 
portionately abundant  on  account  of  the  greater  loss  of 
heat  which  occurs.  The  young  have  a  natural  craving 
for  sugar,  which  may  be  indulged  in  moderation,  as  this 
is  a  valuable  nutrient.  Sweets  are  best  digested  about 
an  hour  after  meals ;  when  given  before  they  disturb 
digestion  by  provoking  secretion  of  mucus.  Growth  and 
development  require  also  an  ample  supply  of  mineral 
elements,  such  as  the  salts  of  potash,  lime,  and  phosphorus, 
these  being  contained  in  the  cereals,  fish,  and  milk.  From 
fifteen  years  onwards,  which  is  perhaps  the  most  active 
period  of  muscular  exertion,  while  the  excretory  organs 
are  in  full  activity,  full  allowances  of  meat  are  required 
and  are  easily  disposed  of.  From  the  time  when  growth 
is  completed  there  should  be  a  gradual  diminution  in 
the  amount  of  food,  particularly  as  regards  the  proteid 
constituents  and  in  accordance  with  the  mode  of  life 
of  the  individual,  bearing  in  mind  the  statement 
already  made,  that  the  output  of  urea  per  day  per 
kilogramme  of  body  weight  gradually  descends  from 
1-35  grms.  at  eighteen  months  to  -5  at  twenty -five 
years. 

In  old  age,  the  lessened  activity  of  chemical  changes 
and  of  the  digestive  and  excretory  functions  demands 
a  lessened  amount  of  food,  especially  in  relation  to  proteid. 


Condiments  223 

Tlie  question  of  digestibility  is  of  special  importance, 
and  one  must  also  take  into  account  defective  powers  of 
mastication.  The  most  suitable  foods  are  broths,  grated 
meats,  eggs,  such  vegetables  as  peas,  beans,  and  lentils, 
besides  an  abundance  of  carbohydrates,  and  in  most  cases 
stimulants,  but  where  there  is  evidence  of  high  arterial 
tension  stimulants  and  nitrogenous  food  should  only  be 
given  in  very  small  quantities. 

Condiments  may  be  regarded  comprehensively  as 
local  stimulants  affecting  appetite  and  digestion,  arrest- 
ing fermentation  and  promoting  secretion  and  peristalsis 
throughout  the  digestive  tract,  when  taken  in  small 
quantities.  Such  are  mustard,  pepper,  vinegar,  sauces, 
pickles,  the  various  spices,  savouries  and  such  easily 
absorbed  articles  as  soup  and  oysters ;  one  or  other  of  which 
condiments  usually  constitutes  part  of  the  food  either 
separately  or  in  the  preparation  of  dishes.  With  these 
may  be  considered  alcoholic  beverages  in  small  amounts, 
such  as  a  glass  or  two  of  light  wine  and  the  smaller  glass 
of  brandy  or  liqueur  with  coffee  at  the  termination  of 
the  meal,  as  digestive  aids. 

The  two  features  which  are  concerned  in  retardation 
of  digestion  are  the  bulk  of  fluid  and  the  quantity  of 
active  principle,  whether  aromatic  or  alcoholic,  when 
taken  in  excess. 

In  the  case  of  some  wines,  however,  the  retarding 
influence  on  digestion  appears  to  be  out  of  proportion 
to  the  amount  of  alcohol  present,  which  is  scarcely  opera- 
tive till  it  amounts  to  10  per  cc-nt.  of  the  gastric  contents. 
Such  are  port,  sherry,  marsala,  and  madeira,  usually 
regarded  as  heavy  wines,  more  appropriate  at  dessert 
than  to  accompany  the  usual  courses. 

On  the  other  hand  hock,  moselle,  claret,  champagne, 
and  perhaps  burgundy  with  the  white  wines  of  cor- 
responding districts,  when  taken  in  moderate  quantity, 
exert  no  deterring  influen^,e  on  the  process  of  digestion 


224  Alcohol 

and  by  slightly  stimulating  the  circulation  counteract 
the  sedative  effect  of  that  process  on  the  brain. 

The  case  of  malt  liquors  is  somewhat  different,  since 
both  by  the  bulk  usually  consumed  and  the  presence 
of  saccharine,  with  other  constituents  besides  alcohol, 
digestion  is  appreciably  delayed  and  fermentation  rather 
encouraged. 

Soup,  as  a  preliminary  to  a  meal,  should  be  taken 
in  very  small  quantity  :  "  three  spoonfuls  "  was  the  amount 
permitted  by  the  late  Sir  Andrew  Clark  to  an  individual 
in  difficulties  with  his  digestion.  Aerated  fluids  whether 
as  sparkling  wine  or  as  mineral  waters  either  alone  or 
with  small  quantities  of  spirit,  tend  to  assist  digestion 
by  slightly  stimulating  the  mucous  membrane  of  the 
stomach  and  aiding  in  the  admixture  of  its  contents. 

Error  in  these  matters  lies  rather  in  the  habit  of 
satisfying  thirst  at  the  commencement  of  a  meal  by 
prematurely  diluting  the  stomach  contents  with  half 
a  pint  or  more  of  fluid,  or  by  over-stimulating  and  thus 
inhibiting  the  function  of  the  mucous  membrane  by 
such  articles  as  cayenne  pepper,  curry,  or  mulligatawny 
soup  in  quantity,  or  by  drinking  strongly  alcoholic 
fluids.  The  practice,  for  instance,  of  drinking  several 
glasses  of  the  various  forms  of  "  cocktail  "  or  gin  and 
bitters  before  a  meal  is  particularly  pernicious  in  this 
respect. 

At  the  end  of  a  meal  the  drinking  of  moderate  quan- 
tities of  fluid  is  not  objectionable,  since  the  food  is  already 
saturated  with  the  digestive  juices  and  partially  dissolved. 

While  taking  food  the  object  aimed  at  is  to  supply 
all  necessary  moisture  through  the  medium  of  the  saliva 
and  gastric  juice  and  not  by  drinking  fluid,  which  should 
be  taken  an  hour  or  more  beforehand  or  he  reserved  for 
the  end  of  the  repast. 

Alcohol  as  a  beverage  must  be  regarded  rather 
as    making    life    temporarily    agreeable    than    as    being 


Alcohol  225 

actually  beneficial  to  the  organism.  In  the  average 
state  of  health  it  cannot  be  regarded  as  necessary.  There 
are  conditions,  however,  somewhat  short  of  perfect 
health,  such  as  old  age,  periods  of  over -work,  and  the 
state  of  fatigue,  in  which  its  beneficial  effects  are  very 
definite,  perhaps  to  a  great  extent  through  its  influence 
on  digestion.  Locally  alcohol  is  an  irritant  when  evapora- 
tion is  prevented,  producing  in  the  mouth  or  stomach 
a  sensation  of  burning  when  introduced  as  neat  spirit, 
more  particularly  in  the  case  of  an  empty  stomach. 
This  may  account  for  the  chronic  pharyngitis  and  gastric 
catarrh  prevalent  in  spirit-drinkers,  and  will  account 
also,  through  stimulation  of  the  salivary  glands,  for  the 
increased  salivation  which  they  experience.  In  small 
quantities,  however,  properly  diluted,  alcohol  is  an  ad- 
junct to  digestion.  Up  to  a  proportion  of  2  per  cent, 
of  the  stomach  contents  it  increases  peristalsis  and 
secretion  of  gastric  juice,  improves  the  appetite,  and 
aids  absorption  of  some  ingredients  of  the  food.  In 
increased  quantity,  up  to  5  or  10  per  cent,  of  the  stomach 
contents,  the  digestion  appears  to  be  somewhat  retarded, 
and  20  per  cent,  admixture  arrests  it. 

The  greater  part  of  the  alcohol  taken  within  moderate 
limits  is  directly  and  rapidly  absorbed  into  the  circula- 
tion. This  rapidity  of  absorption  is  sometimes  taken 
advantage  of  in  accelerating  the  action  of  certain  narcotic 
drugs,  such  as  paraldehyde,  chloral,  and  sulphonal  with 
its  congeners,  when  employed  as  soporifics,  and  is  often 
administered  with  them  for  this  purpose. 

The  rapid  absorption  of  alcohol  by  the  stomach 
prevents  any  considerable  quantity  passing  on  with 
the  chyme  into  the  duodenum,  but  it  is  estimated  that 
a  2  to  3  per  cent,  admixture  is  sufiicient  to  interfere 
with  pancreatic  digestion. 

One  other  effect  of  local  irritant  action  of  alcohol, 
when  taken  in  excess,  appears  to  be  reflex  inhibition  of 

15 


^26  Alcohol 

the  heart's  action  through  the  medium  of  the  vagus 
nerves,  which  may  account  for  sudden  death  after 
SAYallowing  a  large  quantity  of  neat  spirit,  as  much 
as  a  pint  having  been  taken  at  a  time,  generally  for  a 
wager. 

The  principal  effect  of  alcohol  is  that  of  a  stimulant 
to  the  circulation,  its  first  effect  being  to  accelerate  and 
increase  the  force  of  the  heart's  beat,  somewhat  raising 
the  tension  of  the  circulation  with  subsequent  dilatation 
of  peripheral  vessels,  especially  in  the  skin,  associated 
with  perspiration.  This  stimulating  effect  cannot  be 
indefinitely  maintained,  as  reaction  necessarily  occurs, 
consequently  the  beneficial  effects  of  such  stimulation 
can  hardly  be  looked  for  in  habitual  drunkards.  It  is 
on  this  account  that  the  continued  exhibition  of  alcohol 
is  to  be  discouraged  in  cases  of  chronic  disease  of  the 
heart,  and  for  the  most  part  in  acute  forms  of  illness 
the  administration  of  alcohol  should  not  be  commenced 
before  the  real  necessity  for  its  use  arises.  In  febrile 
diseases  and  others  in  which  the  frequency  of  the  heart 
beat  is  increased,  the  beneficial  effect  of  alcohol  is  seen 
in  the  reduction  in  the  number  of  beats,  while  in  cases 
of  heart  failure,  with  feebleness  and  infrequency,  the 
effect  of  alcohol,  when  satisfactory,  tends  to  increase 
the  rapidity  and  force  of  the  heart's  action. 

Acting  in  these  contrary  directions  it  may  be  said  that 
alcohol  proves  beneficial  when  its  effect  is  to  bring  the 
heart's  action  towards  the  normal.  In  the  case  of  fever, 
besides  such  an  effect  on  the  cardiac  beat,  sustaining 
and  steadying  it  alcohol  tends  to  reduce  the  temperature 
by  dilating  the  superficial  vessels,  moistening  the  skin, 
and  so  encouraging  loss  by  radiation  and  evaporation. 
While  it  reduces  ceU  activity  and  with  it  heat  production, 
intervening  between  the  ordinary  food  supply  and  the 
demands  of  the  tissues,  alcohol  appears,  in  being  itself 
oxidised,    to    spare    both    ordinary   nutriment    and    the 


Malt  Liquors  227 

tissues  themselves,  diminishing  the  waste  which  is  a 
constant  accompaniment  of  continued  fever.  Thus, 
in  sparing  fat  and  carbohydrates  and  lessening  cell 
metabohsm  it  acts  practically  as  a  food. 

Malt  LiquoPS. — Malt  liquors  are  obtained  by  the 
fermentation  of  carbohydrates,  the  standard  source 
being  malted  grain,  and  contain,  as  also  do  wines, 
besides  alcohol,  a  considerable  quantity  of  saccharine, 
organic  and  mineral  matter.  The  amount  of  alcohol 
is  low,  usually  not  more  than  4  per  cent.,  so  that  they 
are  almost  as  much  a  food  as  a  stimulant. 

Of  the  various  forms,  lager  beer  is  the  weakest  in 
alcohol,  is  most  aerated,  and  contains  a  considerable 
proportion  of  unchanged  carbohydrate  material,  India 
pale  ale,  which,  though  hght,  is  fully  fermented,  contains 
more  alcohol,  and  very  little  carbohydrate  matter.  These 
are  considered  the  lighter  forms  of  ale.  Ordinary  draught 
or  bottled  ale  is  usually  richer  both  in  alcohol  and  solid 
matter  than  the  preceding  ;  stout  and  porter,  much 
heavier  beverages,  contain  half  as  much  again  both  of 
alcohol  and  extracts.  They  are  also  more  acid  and  more 
difficult  of  digestion,  but  are  excellent  soporifics.  It 
is  chiefly  owing  to  the  saccharine  and  other  organic 
matters  in  the  different  forms  of  malt  liquors  that  these 
are  unsuitable  to  those  predisposed  to  gout,  arthritis, 
and  arterio-sclerosis,  and  indeed  to  all  those  of  sedentary 
habits  who  are  liable  to  what  are  regarded  as  disturbances 
of  the  liver.  Malt  liquors  are  nourishing,  and  form 
excellent  tonics  in  convalescence,  and  are  well  suited 
in  health  to  those  living  a  physically  active  life.  As 
has  been  already  suggested,  they  are  the  best  form  of 
alcoholic  drink  during  the  early  years  of  adult  life.  Later 
on,  when  dissociated  from  physical  activity,  they  tend  to 
produce  obesity  or  gout,  and  are  unsuitable  in  diabetes. 
The  bulk  of  fluid  consumed  in  large  potations  may  lead  to 
distension  of  the  stomach,  and  from  over-fulness  of  the 


22  8  Wines 

circulation  to  dilatation  and  hypertrophy,  followed  by 
failure  of  the  heart. 

Cider  and  PePPy  hold  an  intermediate  position 
between  malt  liquors  and  light  wines.  They  contain 
usually  less  than  4  per  cent,  of  alcohol,  bottled  cider  being 
rather  weaker  in  this  respect  than  draught,  and  re- 
taining more  sugar.  There  is  usually  moderate  acidity 
due  to  malic  and  citric  acids.  These  have  apparently 
rather  a  beneficial  influence  in  rheumatism  and  gout, 
being  solvents  of  uric  acid  ;  and  a  fairly  dry  sample  of 
this  beverage  may  be  drunk  by  patients  prone  to  these 
diseases,  much  in  the  same  way  as  hock,  but  the  sweet 
aerated  bottled  ciders  are  not  so  suitable. 

Wines. — Wines  are  obtained  by  fermenting  the  juice 
of  the  grape,  resembling  malt  liquors  in  that  they 
contain  a  considerable  amount  of  dissolved  organic 
matter,  in  addition  to  a  percentage  of  alcohol,  with 
the  addition  of  particular  ethers. 

Natural  wines,  in  which  the  grape  juice  is  fully  fer- 
mented, contain  a  relatively  small  amount  of  alcohol, 
less  than  12  per  cent,  by  weight,  and  practically  no  sugar. 
They  are  light  in  character,  whether  red  or  white,  mature 
early,  are  not  sweet,  and  supply  the  best  beverage  with 
meals.  Such  are  hock  and  moselle,  and  the  red  and  white 
wines  of  Burgundy  and  Bordeaux.  With  these  may 
be  included  the  wines  of  Hungary,  Italy,  Australia,  and 
California,  The  different  qualities  of  wine  depend  both  on 
the  yeast  and  the  grape  employed  in  their  manufacture. 

Fortified  wines  contain  alcohol  to  nearly  double 
the  amount  present  in  the  natural,  this  being  provided 
by  added  spirit,  which  limits  the  extent  of  fermentation, 
80  that  these  wines  contain  in  addition  a  high  proportion 
of  sugar.  Such  are  port,  sherry,  marsala,  madeira,  and 
the  Greek  wines,  which  on  account  of  the  alcohol  and 
sugar  they  contain,  as  in  the  case  of  malt  liquors,  are 
unsuitable  for  gouty  and  arthritic  subjects. 


spirits  229 

The  proportion  of  alcohol  and  ethers  increases  while 
the  wine  is  in  the  vats  and  the  ethers  still  further  after 
the  wine  is  bottled,  with  slight  sacrifice  of  alcohol. 
These  changes  cause  the  wines  to  mellow  with  time.  They 
do  not,  however,  continue  indefinitely,  but  the  greater 
their  strength  in  alcohol  the  longer  wines  take  to  mature 
and  the  longer  they  may  be  kept  to  advantage. 

It  will  be  inferred  from  the  foregoing  observations 
that  the  natural  wines,  including  with  them  champagne, 
are  best  fitted  to  accompany  a  meal,  fortified  wines  being 
suited  for  occasional  use  and  dessert,  in  much  smaller 
quantities. 

Spirits  as  usually  sold  contain  about  43  per  cent,  of 
alcohol,  rum  rather  more,  and  gin  a  little  less.  Patent 
spirit,  which  forms  a  large  proportion  of  that  usually 
obtainable,  is  freer  from  by-products  than  pot-still 
spirit,  and  does  not  therefore  improve  to  any  per- 
ceptible degree  by  keeping.  Rum,  which  is  fermented 
molasses,  or  the  juice  of  the  sugar-cane,  owes  its  flavour 
chiefly  to  ethyl  butyrate  and  its  colour  to  burnt  sugar. 
It  contains  a  larger  amount  of  solid  matter  than  any 
of  the  other  spirits,  besides  being  as  a  rule  stronger  in 
alcohol.  It  is  seldom  used  medicinally,  except  as  a 
mixture  of  rum  and  milk  as  a  morning  draught,  par- 
ticularly in  cases  of  consumption.  Whisky,  which  may 
be  regarded  as  distilled  beer  apart  from  the  hops,  is 
about  half  and  half  alcohol  and  water,  its  colour  being 
obtained  from  being  kept  in  sherry  casks.  It  is  slightly 
laxative,  contains  rather  more  alcohol  than  brandy,  and 
is  considerably  cheaper  and  easier  to  procure  than  that 
spirit,  and  is  perhaps,  therefore,  preferable  for  general  use. 

Brandy,  which  is  distilled  wine,  derives  its  colour, 
and  perhaps  some  degree  of  astringency,  from  the  wood 
of  the  oak  casks  in  which  it  is  kept.  Both  brandy  and 
whisky,  other  than  patent  spirits,  are  mellowed  by  time 
through   development   of   ethers   and   aldehydes  with  a 


230  Spirits 

slight  reduction  in  the  percentage  of  alcohol.  The  best 
brandies  are  derived  from  Cognac  and  Spain. 

For  cases  with  severe  nervous  and  circulatory  depres- 
sion old  liqueur  brandy  is  the  very  best  stimulant,  and 
it  should  be  reserved  for  such  infrequent  cases,  being 
expensive  and  difficult  to  procure.  Owing  to  the  smaU 
amount  of  tannin  present,  brandy  is  regarded  as  some- 
what constipating,  and  is  occasionally  employed  as  a 
household  remedy  in  diarrhoea. 

Gin  is  distilled  from  fermented  rye  and  malt  liquor, 
flavoured  with  juniper.  Being  kept  in  cisterns  lined 
with  white  tiles  it  remains  colourless.  The  best  is  made 
in  Schiedam,  Holland.  Gin  is  a  somewhat  weaker  spirit 
than  the  others,  containing  35  per  cent,  of  alcohol,  and  very 
little  else  than  this.  It  may  therefore  be  looked  upon 
as  perhaps  the  purest  spirit,  quite  free  from  sugar,  and 
on  this  account  and  the  presence  of  oil  of  juniper  it  is 
often  selected  as  a  stimulant  in  cases  where  the  kidneys 
are  defective  and  a  diuretic  action  is  required.  Another 
advantage  of  gin  is  that  it  is  relatively  inexpensive.  There 
being  little  in  it  to  undergo  secondary  changes,  it  is 
practically  as  good  when  first  made  as  when  kept,  and 
this  materially  diminishes  its  cost  in  comparison  with 
other  spirits. 

Where  there  is  great  nervous  depression  associated  with 
delirium,  dry  tongue,  and  tremors,  alcohol  is  of  striking 
oenefit.  Its  physiological  effects  on  the  circulation  are  ex- 
perienced in  the  sense  of  warmth  due  to  flushing  of  the 
skin,  and  in  mental  activity,  associated  with  dilatation  of 
the  cerebral  vessels  ;  but  the  fallaciousness  of  these  im- 
pressions is  shown  in  the  one  case  by  the  increased  loss  or 
diminished  production  of  heat,  often  illustrated  in  deaths 
from  cold  and  exposure  after  excess  of  alcohol,  and  in 
the  other  by  the  reactionary  depression  and  really  defec- 
tive ideas  due  to  cell  paralysis.  It  may  be  inferred  from 
this  that  alcohol  is  not  a  true  brain  stimalant,  and  that 


Spirits  231 

while  it  increases  vulnerability  to  cold  when  taken  during 
or  before  exposure,  it  may  be  of  service  after  chill  by 
assisting  the  activity  of  the  circulation  and  the  more 
general  distribution  of  the  blood  which  has  been  retained 
internally  by  congestion.  Long-continued  use  of  alcohol 
produces  vascular  paralysis,  and  accounts  for  the  bloated 
look  and  purple  complexion  of  the  chronic  drunkard. 
The  injury  to  the  organism  wrought  by  excess  of  alcohol, 
besides  the  local  catarrh  already  mentioned,  apparently 
depends  on  the  passage  of  a  proportion  of  the  unchanged 
drug  through  the  system,  some  10  per  cent,  escaping  oxida- 
tion. This  free  alcohol  acts  as  an  irritant  in  the  circula- 
tion, causing  fibrosis  in  the  liver,  blood  vessels,  brain,  and 
kidneys.  Such  effects  are  most  marked  when  a  large 
quantity  is  taken  at  once,  especially  when  undiluted. 
The  limit  of  absolute  alcohol  that  can  be  disposed  of  in 
the  system  at  one  time  is  from  1  to  1|-  fluid  ounces 
(which  would  be  represented  by  some  2  ounces  of 
spirit,  5  ounces  of  strong  wine,  such  as  port  or  sherry, 
^  pint  of  light  wine  or  champagne,  and  about  1 
pint  of  beer).  The  danger  to  be  avoided  therefore  is 
flooding  the  circulation  with  an  amount  of  alcohol  which 
it  is  beyond  the  power  of  the  tissue  cells  to  oxidise. 
Other  effects  of  excess  of  alcohol,  short  of  actual  inebriety, 
are  fatty  degeneration  of  tissues  and  obesity.  Idiosyn- 
crasy has  much  influence,  and  an  open  air  life  with 
constant  activity  does  much  to  neutralise  the  effects  of 
alcohol,  and  an  amount  which  would  exceed  the  capacity 
of  the  organism  to  deal  with  in  one  dose  may  be  tolerated, 
if  sufficiently  diluted,  or  taken  in  subdividei'  quantities 
in  the  course  of  the  day. 

As  a  beverage  alcohol  is  less  noxious  when,  taken  with 
meals,  provided  the  quantity  is  below  that  \Fhich  would 
unfavourably  dilute  the  gastric  contents.  For  the  most 
part,  beer  is  best  suited  to  youth,  wine  to  middle  a^e, 
and  spirits  to  the  ol4. 


232  Spirits 

In  connection  with  disease,  spirits  are  usually  employed 
in  acute  phases,  whether  as  a  "  sparing  "  aliment  in 
fevers  or  as  a  direct  stimulant  to  the  circulation  in 
cases  of  heart  failure.  The  combination  of  tincture  of 
digitahs  or  strophanthus  in  the  proportion  of  a  drachm 
to  three  or  six  ounces  of  spirits  in  the  course  of  twenty- 
four  hours  supplies  an  efficient  heart  tonic. 

Stimulants  should  of  course  be  given  with  the  same 
strict  dosage  and  regularity  as  medicine,  and  it  should 
not  be  forgotten  that  when  really  required  they  are  most 
necessary  during  the  night.  It  is  sometimes  advisable 
rather  to  prescribe  alcohol  in  such  a  form  as  the  following  : 


Tinct.  Aurantii 

.        .        .        oij 

Sp.  ^theris     . 

3  S3 

Sp.  Am.  Aromat. 

3ss 

T.  Nucis  Vomicse     . 

.     mx 

Aq.  Chloroformi 

.  adgj 

This  is  a  powerful  diffusible  stimulant  which  would  not 
be  recognised  in  a  prescription  as  alcohol. 

Malt  liquors  and  the  fortified  wines  are  chiefly  used 
in  convalescence  from  acute  disease,  sherry  being  revived 
at  the  present  time,  though  port  has  long  held  first  place. 
Champagne  is  of  special  service  in  rousing  patients  who 
are  particularly  exhausted  or  when  there  is  frequent 
vomiting  and  nausea,  and  has  been  much  used  in  influenza. 
It  is  speedy  though  transient  in  its  effects,  and  when  taken 
with  meals  is  of  great  value  in  assisting  appetite. 

Port  has  for  a  long  time  been  regarded  as  of  particular 
value  in  septic  states  both  general  andlocal,beingemployed 
in  septic  infection  and  intoxication  and  especially  in 
cases  of  septic  sore  throat. 

The  natural  wines  with  cider  and  perry  are  wholesome 
general  beverages  in  health,  as  are  also  malt  liquors  for 
those  leading  an  active  life,  but  in  arthritis  and  those 
suffering  with  arterial  and  renal  degeneration  the  lightest 
white  wines  are  alone  admissible. 


Coffee  233 

The  immediate  effect  of  nerve  stimulants,  without 
actually  supplying  nutriment,  is  to  excite  the  individual  to 
exert  his  powers  of  resistance  and  activity,  apparently  by 
enabling  certain  reserves  of  energy  and  energy-supplying 
material  to  be  drawn  upon  through  the  agency  of  the 
nervous  system.  Such  stimulants  are  excitants  which  do 
not  take  the  place  of  food  nor  diminish  the  expenditure  of 
nutritive  material  in  the  body,  consequently  they  exert 
their  influence  in  bringing  about  activity  at  the  expense 
of  the  materials  already  existing  in  the  body.  Ex- 
cluding alcohol,  the  nerve  stimulants  contain  alkaloids 
of  the  puric  family  allied  to  xanthin  and  uric  acid. 
These  are  coffee,  tea,  mat6,  cocoa,  kola,  and  guarana, 
though  there  are  other  substances  which  have  a  share 
in  the  stimulating  effect  besides  the  recognised  alkaloid 
in  each  individual  case.  It  has  been  stated  by  Le  Blond 
that  caffeine  increases  the  central  and  diminishes  the 
peripheral  temperature  of  animals.  It  stimulates  the 
action  of  the  heart  when  given  in  moderate  doses,  causing 
arterial  pressure  to  rise  both  by  this  and  by  contraction 
of  the  peripheral  vessels.  It  increases  the  activity  of 
the  nervous  centres  and  the  excitability  of  the  muscles, 
causing  the  sensation  of  fatigue  to  disappear  ;  but  its 
chief  effect  is  in  inducing  a  greater  amount  of  brain  or 
mechanical  work  to  be  done  upon  the  same  amount  of 
food. 

Coffee  helps  the  digestion  of  milk  and  is  less  liable 
to  interfere  with  that  of  proteid  matters  such  as  meat 
than  is  tea.  Its  effects  on  the  nerve  centres  are  valuable 
in  taking  the  place  of  alcohol,  and  even  in  curing  chronic 
alcoholism.  When  taken  in  excess  or  by  individuals 
unaccustomed  to  its  effects,  coffee  is  liable  to  produce 
nervous  excitement  and  especially  insomnia ;  and  in 
great  excess  the  condition  produced  is  comparable  with 
advanced  alcoholism.  It  should  be  forbidden  in  the 
arthritic  and  uratic  diatheses,   to  those  suffering  from 


234  Tea 

gastrodynia  and  dyspepsia,  or  Bright's  disease.  As  an 
antidote  it  is  commonly  used  in  opium  and  belladonna 
poisoning,  as  well  as  in  that  by  alcohol. 

Tea  is  no  more  of  a  food  than  coffee,  but  it  has  a 
similar  power  of  exciting  functional  activity  of  the  nervous 
and  muscular  systems  so  that  a  greater  amount  of  work 
can  be  done  under  its  influence  with  the  same  amount 
of  food,  and  without  the  usual  sense  of  effort.  It  also 
excites  the  circulation,  the  digestive  functions  and  the 
kidneys,  by  its  alkaloids.  The  use  of  tea  should  be 
restricted  in  nervous  subjects,  and  in  those  suffering  from 
gastric  disturbances.  Owing  to  its  exciting  the  activity 
of  the  skin,  it  is  also  unsuitable  for  those  suffering  from 
diseases  such  as  eczema.  Both  tea  and  coffee,  on  account 
of  their  being  allied  to  uric  acid,  are  considered  inadmis- 
sible in  the  subjects  of  chronic  gout.  An  important 
point  to  remember  in  the  preparation  of  tea  is  that  the 
amount  of  tannin  dissolved  increases  with  the  time 
occupied  in  infusing.  Five  minutes  or  less  should  dis- 
solve the  thein  and  about  one-third  of  the  tannin ;  pro- 
longed infusion  serves  only  to  extract  further  quantities 
of  tannin,  colouring  matters  and  a  bitter  principle. 
For  the  most  part  it  is  the  tannin  which  disturbs  the 
stomach  and  interferes  with  the  digestion  of  proteids. 
To  make  good  tea  cold  water  should  be  freshly  boiled, 
and  the  teapot  completely  filled.  The  presence  of  lime 
salts  interferes  to  some  extent  with  the  extraction  of  its 
constituents,  and  hard  water  should  be  softened  with  a 
little  bicarbonate  of  soda.  On  the  other  hand  too  soft 
a  water  extracts  the  bitter  principle  from  the  leaf.  The 
use  of  water  which  has  been  previously  boiled  or  long 
heated,  owing  to  the  absence  of  dissolved  air,  gives  a 
flat  taste  to  the  beverage.  The  importance  of  heating 
the  teapot  and  employing  actually  boiling  water  depends 
on  the  fact  that  some  of  the  volatile  constituents  of  the 
lesbi   which  supply  the  aroma  can  only  be  properly  ex- 


Chocolate  235 

tracted  at  the  boiling  point.  The  water  should  not 
remain  in  contact  with  the  leaves  for  more  than  five 
minutes,  or  the  infusion  will  become  bitter  and  astringent. 

The  addition  of  milk,  by  forming  an  insoluble  com- 
pound with  the  tannin,  appears  to  obviate  some  of  the  ill- 
effects  of  tea  on  the  digestive  processes,  but  even  then  tea 
is  an  unsuitable  beverage  in  association  with  meat  meals. 
Irritating  effects  on  the  stomach  are  more  likely  to  occur 
when  this  is  otherwise  empty,  and  is  an  objection  to  the 
early  morning  cup  taken  alone.  As  an  habitual  beverage 
coffee  appears  to  exert  a  relaxing  effect  on  the  bowels 
and  tea  the  opposite.  The  ill-effects  of  both  tea  and 
coffee  show  themselves  in  a  disturbance  of  digestion 
and  over-excitability  of  the  nervous  system.  Coffee  is 
often  considered  "  bilious  "  and  tea  as  productive  of 
dyspepsia.  These  effects  usually  result  from  excess, 
or  depend  on  personal  idiosyncrasy. 

Choeolate. — The  third  substance  used  as  a 
beverage  differs  from  the  other  two  in  that  it  contains 
more  nutriment  and  less  constituents  of  a  stimulating 
character.  Theobromine,  its  peculiar  alkaloid,  is  homonj'- 
mous  with  caffeine,  and  has  very  similar  effects.  Its 
richness  in  albuminoids  and  fatty  matters,  with  the  large 
amount  of  sugar  which  is  added  in  manufacture,  make 
up  a  food  of  great  nutritive  value.  Owing  to  the 
presence  of  oxalates  in  considerable  quantity,  and  also 
the  large  proportion  of  sugar,  chocolate  is  unsuited  for 
those  suffering  from  uric  acid  or  arthritic  diatheses, 
rheumatic  or  gouty  subjects,  and  those  tending  to  obesity. 
Chocolate,  being  both  a  stimulant  and  a  food,  produces 
a  more  lasting  effect  than  tea  or  coffee,  with  less  excite- 
ment, and  consequently  forms  a  satisfactory  drink 
before  going  to  bed  and  in  insomnia  from  hunger  in 
the  course  of  the  night. 

Of  the  other  stimulants  mentioned,  Kola  contains  a 
sustaining  substance  allied  to  thein,  and  is  used  as  ai? 


236  Vegetarian  Diet 

actual  nerve  stimulant,  forming  a  factor  in  Vi-cocoa. 
The  kola  -bean  is  largely  employed  by  negroes  in  Central 
and  Western  Africa  as  a  sustaining  food,  enabling  them 
to  resist  the  fatigue  of  long  journeys  for  days  together 
with  no  other  substance  than  water. 

Mate,  an  infusion  of  which  is  extensively  employed 
in  South  America,  has  very  much  the  qualities  of  tea,  the 
stimulating  properties  being  due  to  nearly  2  per  cent,  of 
thein  and  20  per  cent,  of  metatannic  acid.  The  infusion  is 
slightly  bitter,  aromatic,  and  astringent,  and  is  a  neuro- 
muscular excitant. 

Guapana,  which  has  been  mentioned  as  a  remedy 
in  headache,  is  used  in  Brazil  infused  with  boiling  water 
much  in  the  same  way  as  tea,  to  aid  in  resisting  hunger 
and  fatigue  during  journeys.  Tannate  of  caffeine  amount- 
ing to  4  per  cent,  is  the  chief  active  principle. 

SPECIAL  DIETS. 

Vegetarian  Diet. — It  may  be  inferred  from 
what  has  been  already  written  that  the  nitrogenous  as 
well  as  the  carbohydrate  principles  of  food  may  be 
entirely  supplied  by  the  vegetable  kingdom.  This 
appears  to  be  particularly  suitable  in  hot  climates,  and 
prevails  largely  in  India  and  Egypt  as  well  as  in  many 
parts  of  Russia  and  Norway,  without  any  sacrifice  of 
energy,  though,  as  in  the  case  of  herbivorous  animals, 
such  a  diet  appears  more  suited  to  steady  continuous  strain 
than  to  concentrated  effort.  Its  advantages  are  largely 
those  of  temperance,  tendency  to  arthritic  or  gouty 
diatheses  being  diminished,  and  the  general  tenor  of 
life  being  rendered  more  equable,  without  loss  of  intel- 
lectual acuteness.  It  also  has  the  advantage  of  being 
inexpensive. 

On  the  other  hand,  the  bulk  of  food  required,  and 
its  constitution,  puts  a  greater  strain  on  digestion,  and 


Milk  Diet  237 

is  ill  suited  to  meet  the  lowered  vitality  incident  to 
faulty  heredity,  illness,  or  advanced  age.  The  amount 
of  vegetable,  as  compared  with  animal  food,  in  regard 
to  proteid,  averages  in  different  substances  from  two  to 
ten  times  the  bulk,  so  that  in  order  to  obtain  sufficient 
alimentation  from  vegetable  sources  alone  the  vegetarian 
necessarily  encumbers  his  system  as  well  as  his  stomach 
and  alimentary  canal  with  an  excessive  volume  of  material 
containing  much  superabundant  and  useless  matter.  As 
compared  with  herbivorous  animals  the  human  organism 
is  neither  suited  to  deal  with  such  bulk,  nor  is  it  able 
to  digest  cellulose,  which  forms  a  considerable  propor- 
tion of  vegetable  matter.  Such  a  form  of  diet,  however, 
is  rendered  possible  by  the  addition  of  such  animal 
foods  as  butter,  milk,  and  eggs,  and  perhaps  fish.  The 
adoption  of  vegetarian  diet  results  in  an  increase  in  faecal 
residues  which  stimulate  the  activity  of  the  colon  and  so 
diminishes  constipation,  tends  to  render  the  urine  more 
alkaline  than  would  be  the  case  with  animal  food,  and 
further,  by  diminishing  the  supply  of  nitrogen,  relieves 
the  liver  and  kidneys  from  the  elaboration  and  removal 
of  nitrogenous  products.  A  largely  vegetable  diet,  on 
the  other  hand,  tends  to  the  production  of  flatulence. 
It  increases  the  alkalinity  of  the  blood,  accelerates 
oxidation,  and  diminishes  nitrogenous  losses  and  the 
development  of  toxins.  It  is  therefore  specially  suited 
for  cases  of  renal  disease,  and  it  exerts  a  favourable 
influence  on  many  diseases  of  the  skin,  tendency  to 
arterio-sclerosis,  arthritis  and  congestion  of  internal 
organs  particularly  when  associated  with  a  gouty  diathesis. 
Milk  Diet. — From  the  analysis  of  milk  previously 
cited,  it  will  be  seen  that  under  no  circumstances  can 
this  offer  a  permanently  complete  form  of  nourishment 
to  an  adult,  the  quantity  of  albuminoids  being  too  great 
in  proportion  to  carbohydrates.  The  addition  of  bread, 
however,  produces  a  complete  diet  on  which  an  individual 


238  Meat  Diet 

might  live  indefinitely.  An  adequate  milk  diet  for  an 
invalid  may  be  considered  to  include  3  pints  of  milk, 
with  10  ounces  of  bread,  and  about  IJ  ounces  of  rice 
or  tapioca  as  pudding.  Such  a  diet  is  suitable  to  con- 
ditions of  fever  in  which  a  relatively  large  proportion 
of  liquid  is  required,  and  where  the  digestive  capacity 
is  reduced  in  a  serious  degree. 

From  the  point  of  view  of  elimination  of  nitrogenous 
products,  such  a  diet  is  commonly  prescribed  in  renal 
diseases,  though  it  may  be  necessary  to  reduce  the  amount 
of  fluid  while  there  is  increasing  oedema.  An  important 
point  also  to  be  attended  to  is  the  reduction  of  mineral 
matters,  particularly  common  salt,  which  tends  to  increase 
the  transudation  of  albumen. 

Owing  to  the  constipating  effeots  of  a  milk  diet,  the 
addition  of  barley  water  or  a  decoction  of  oatmeal  is 
usually  necessary.  It  is  important  with  a  diet  of  milk 
that  this  should  only  be  taken  in  very  small  draughts 
at  a  time,  and  rather  slowly,  while  the  admixture  of 
lime-water  in  the  proportion  of  an  ounce  to  a  pint 
diminishes  the  tendency  to  form  hard  curd.  It  may  be 
mentioned  that  many  persons  with  whom  milk  disagrees 
in  health  are  able  to  take  it  in  illness  owing  to  lessened 
acid  secretion  in  the  stomach. 

Meat  Diet. — This  supplies  the  greatest  amount  of 
energy  at  short  notice  and  in  the  smallest  bulk,  and  is 
suited  to  healthy  individuals  leading  an  active  life  in 
which  great  and  sudden  demands  may  be  made  on  the 
energy  and  courage.  In  the  absence  of  fat  and  carbo- 
hydrates in  the  diet  these  matters  are  removed  from  the 
body,  such  diet  being  therefore  suitable  for  the  reduction 
of  obesity.  An  animal  diet,  with  due  proportion  of  fat, 
is  of  necessity  employed  in  cases  of  diabetes  to  avoid  the 
development  of  sugar. 

The  chief  disadvantage  of  a  meat  diet  is  in  the  pro- 
duction of  superabundant  nitrogenous  waste,  especially 


Obesity  239 

uric  acid  ;  and  the  amount  of  work  thrown  on  the  liver 
results  in  dyspepsia,  skin  eruptions,  and  constipation, 
from  the  relatively  small  bulk  and  tenacity  of  the  faeces. 
It  is  one  of  the  most  active  predisposing  causes  of  arterio- 
sclerosis. 

In  Obesity  it  is  necessary  to  reduce  as  far  as  possible 
fats,  saccharine,  and  starchy  matters,  replacing  them  by 
some  increase  of  meat  and  salads,  also  raw  fruits,  the 
omission  of  condiments  and  spices  tending  to  diminish 
appetite.     Such  a  diet  would  consist  of  : 

Gautier 


rl  egg. 

8  o'clock    .         . 

.     ■]  ^  oz.  bread. 

If  oz.  meat. 

/-2  eggs. 

10  o'clock           . 

,     J  J   oz.  bread. 

1,6  oz.  wine  and  water. 

'\  lb.  lean  meat. 

1  oz.  bread. 

12  o'clock           . 

•      1  5  oz.  green  vegetables  with  a  simi- 

^     lar  quantity  of  wine  and  water. 

4  o'clock    .         , 

.      Tea  without  sugar. 

7  o'clock    . 

.       A  similar  meal  to  that  at  12. 

This  diet  supplies  1,290  calories  per  day,  rather  more 
than  half  that  actually  expended  in  a  state  of  relative 
repose,  the  remaining  800  or  900  calories  being  compul- 
sorily  borrowed  from  the  combustion  of  stored-up  fats, 
loss  of  weight  being  at  the  rate  of  nearly  1  lb.  a  day. 

Alcoholic  beverages  in  any  quantity  must  be  excluded, 
but  there  is  no  need  greatly  to  reduce  the  amount  of 
fluid.  Indeed,  hot  water  appears  to  have  a  special 
influence  in  reducing  fat.  Skimmed  milk  may  be  allowed, 
as  the  fatty  matters  have  been  largely  removed. 

The  cure  of  obesity  may  be  assisted  by  moderate 
exercise,  warm  drinks,  and  light  purgatives,  as  in  the 
regime   adopted   at   Marienbad.     Although   the   use   of 


240  Obesity 

thyroglandin  reduces  the  weight  of  the  body,  by  pro- 
ducing cardiac  disturbance,  and  increasing  nitrogenous 
waste,  it  is  a  less  safe  and  satisfactory  method  than  that 
by  diet  alone.  Here  may  be  appended  an  account  of 
the  purely  nitrogenous  diet  described  by  Dr.  Salisbury. 

In  the  first  stage  the  diet  is  restricted  practically 
to  meat  and  hot  water. 

The  muscle  pulp  of  beef  is  most  recommended,  and 
this  made  into  cakes  is  broiled  and  then  seasoned  with 
butter,  pepper,  and  salt.  The  use  of  certain  sauces, 
of  mustard,  horse-radish,  or  lemon  juice  is  permitted. 
A  little  celery  as  a  rehsh  is  allowed. 

This  constitutes  the  meal — there  may  be  an  occasional 
change  to  broiled  mutton — and  it  is  repeated  three  times 
daily. 

Nothing  is  drunk  at  the  meal,  but  at  about  one  and 
a  half  or  sometimes  two  hours  before  the  next  meal  half 
a  pint  to  a  pint  of  hot  water  at  a  temperature  of  from 
110°  to  150°  Fahr.  {i.e.  at  about  the  temperature  of  one's 
hot  tea  or  coffee)  is  sipped — fifteen  to  thirty  minutes  being 
taken  over  the  drinking  of  the  water.  Should  the  water 
nauseate,  Dr.  Salisbury  recommends  that  a  little  salt 
should  be  sprinkled  in,  or  a  small  quantity  of  clear  tea 
or  coffee,  or  half  a  teaspoonful  of  aromatic  spirits  of 
ammonia.  He  gives  as  the  best  times  for  the  hot  water 
6  a.m.,  11  a.m.,  4  p.m.,  and  9  p.m.  before  retiring.  The 
duration  of  the  treatment  will  depend  very  much  upon 
the  nature  of  the  trouble,  and  upon  the  mode  of  reaction 
to  the  diet.  The  hot-water  part  is  recommended  to  be 
continued  for  months  or  even  for  years.  The  exclusive 
meat  diet — half  a  pound  to  a  pound  or  even  more  is 
taken  at  each  meal — may  be  continued  for  some  two  to 
six  weeks,  and  then  gradually  the  choice  of  vegetables 
may  be  increased  and  some  thoroughly  cooked  bread 
foods,  such  as  baked  chip  bread,  thin  dry  toast,  rice,  etc., 
introduced.     Before  this,  or  along  with  it,  it  will  have 


Obesity  241 

been  allowable  to  extend  the  scale  of  meats  as  follows : 
broiled  mutton  and  lamb,  broiled  game,  broiled  chicken, 
broiled  codfish,  broiled  and  baked  fish  free  from  fat, 
a  soft-boiled  egg,  etc.  Subsequently,  health  being  re- 
stored, it  is  recommended  to  keep  the  starchy  foods  well 
in  the  background,  the  albuminate  being  the  most  pro- 
minent.    Resting  before  and  after  the  meal  is  advocated. 

Directions  for  cooking  the  beef  cakes  (according  to 
Dr.  Salisbury's  plan) : 

"  Take  four  ounces  of  the  beef  pulp,  which  has  been 
nicely  minced,  as  before  directed,  and  freed  from  all 
connective  tissue  and  fat,  etc. ;  season  with  black  pepper 
and  salt,  but  add  no  liquid.  With  two  forks  form  it 
nicely  and  quickly  into  round  flat  cakes  from  a  half  to  one 
inch  thick,  and  broil  them  slowly  and  moderately  well, 
over  a  clear  but  not  a  fierce  fire,  turning  the  griller  every 
minute.  They  will  take  from  six  to  eight  minutes.  If 
pressed  hard  and  tight  in  the  making,  they  are  livery, 
not  nice,  and  very  indigestible.  A  small  piece  of  fresh 
butter  may  be  put  on  each  cake  when  done  ;  serve  on 
a  flying  hot  plate." 

We  may  remember  that  Dr.  Salisbury  allows  certain 
sauces  :  Worcester  or  Halford's,  also  mustard,  horse-radish, 
lemon  juice — a  selection  from  these. 

Mince. — A  thick  steak  from  the  top  of  the  round,  or 
prepared  ox  heart  quite  fresh,  with  all  skin  and  fat 
removed,  is  finely  minced.  The  pulp  should  be  put  in  the 
saucepan  with  salt  and  black  pepper,  and  cold  water  or 
well  skimmed  gravy  in  the  proportion  of  a  full  dessert- 
spoonful to  each  ounce  of  the  pulp.  (If  the  meat  is 
specially  dry,  add  a  little  more  liquid.)  Beat  it  all 
well  together  to  a  thick  cream. 

The  saucepan  must  now  be  put  on  a  cool  part  of  the 
stove  or  range,  and  the  pulp  warmed  through  very 
gradually,  and  very  slowly  cooked,  being  briskly  stirred 
and  beaten  up  with  a  wooden  spoon  the  whole  time. 

16 


242     Arthritist  Gout,  Uric  and  Oxalic  Gravel 

It  should  never  get  too  hot  to  the  touch  while  cooking 
(temperature  about  115°  Fahr.).  If  gradually  and 
gently  cooked  thus,  it  takes  from  twenty  to  thirty  minutes 
according  to  quantity,  and  should  be  turned  out  at 
once,  when  done,  into  a  hot  bowl  and  covered.  If  properly 
cooked,  it  is  delicious,  like  a  thick  smooth  cream. 

Apthpitis,  Gout,  Upie  and  Oxalie  Gravel. 
— Though  the  subject  of  these  maladies  does  not  always 
eat  in  excess  of  others,  it  is  certain  that  many  exceed 
the  limit  of  strict  necessity,  and  the  power  which  they 
have  of  consuming  completely  the  food  they  take. 
Organic  hyperacidity  is  the  rule  in  arthritics,  necessitating 
alkalinity  of  the  diet.  This  requires  restriction  in  all 
acid  dishes  except  such  organic  acids  as  vinegar,  lemon 
juice,  and  fruits.  A  meat  diet,  since  it  tends  to  the 
development  of  organic  acids  of  nitrogenous  constitution, 
must  be  suppressed  or  reduced  in  amount.  Neither 
fortified  wines,  liqueurs,  malt  liquors,  coffee,  nor  chocolate 
are  admissible  in  such  cases.  The  diet  must  be  scanty, 
including  a  little  bread  and  carbohydrates  (although 
potatoes  may  be  taken),  still  less  meat,  and  few  fatty 
bodies  which  impede  nitrogenous  metabolism,  but  in 
place  of  them  a  great  deal  of  green  vegetables  and  ripe 
fruits. 

An  indoor  life  is  as  far  as  possible  to  be  discouraged. 

As  regards  meat,  the  flesh  of  young  animals  and  the 
gelatinous  parts  are  particularly  to  be  avoided,  as  well 
as  smoked  meats,  and  such  as  are  rich  in  nuclein, 
as  sweetbreads,  brains,  and  eggs.  Such  vegetables  as 
spinach,  sorrel,  and  rhubarb,  w^hich  contain  much  oxalio 
acid,  should  be  eschewed.  Milk  is  the  best  nutrient, 
supplying  the  place  of  meat  on  the  nitrogenous  side, 
and  a  relative  excess  of  fluid,  which  is  favourable. 

With  regard  to  beverages,  pure  water  in  abundance 
excites  oxidation,  and  holds  in  solution  uric  acid,  but 
most  mineral  waters  answer  the  purpose,  especially  the 


Diabetes 


^43 


alkaline  and  laxative  varieties.  Light,  non-acid  wines, 
fruit  juices,  draught  cider,  lager  beer,  and  weak  tea  are 
admissible. 

At  Carlsbad  the  diet  prescribed  for  gouty  patients 

is  as  follows  : 


Breakfast 


/'Weak  tea  with  cream. 
J  Biscuits,  2  to  4  oz. 
j  Butter,  J  oz. 
\^2  soft-boiled  eggs. 


Midday  Dinner 


Supper 


Soup,  either  clear   or  with  pearl 

barley  or  rice,  1  oz. 
Fish,  3^  oz.,  with  melted  butter 

and  lemon  juice. 
Potatoes,  2  oz. 
Roast  meat,  3|  oz. 
Cheese,   1  oz. 
Stewed  fruit,  3^  oz. 
.Bread,  5  oz. 

(Soup,  milk  or  weak  tea. 
Biscuits. 
Lean  bacon  or  1  or  2  egga. 


With  dinner  and  supper  pure  or  mineral  water,  with 
half  a  pint  of  light  claret  or  two  tablespoonfuls  of  whisky, 
is  allowed. 

Diabetes. — In  this  disease  there  is  excessive  loss 
of  water,  sugar,  and  nitrogenous  bodies,  which  have 
to  be  limited  and  made  good  as  far  as  possible  by  modifica- 
tions in  the  food  taken.  These  consist  in  (1)  eliminating 
as  far  as  possible  every  article  of  diet  which  may  furnish 
glucose,  and  (2)  meeting  the  nitrogenous  losses  by  an 
increased  amount  of  animal  food.  Plenty  of  fluid  must 
be  given,  a  considerable  amount  of  meat,  while  the 
carbohydrates  are  replaced  by  green  vegetables  and  fats 
in  various  forms.  Fruits,  containing  as  they  do  starch  and 
sugar,  though  in  small  proportion,  may  only  be  tolerated 
in  small  quantities.  Objection  does  not  extend  to  such 
as  are  not  sweet,  as   tomatoes,   olives,  and   hard  nuts 


244  Nephritis 

such  as  almonds,  walnuts,  filberts,  etc.  Such  starchy 
fruits  as  bananas  and  chestnuts,  and  very  sweet  ones 
such  as  grapes  and  cherries,  should  be  forbidden.  The 
general  rule  is  to  avoid  the  roots  and  fruits  and  only 
to  eat  the  intermediate  stalks  and  leaves,  remembering 
that  white  stalks  contain  some  starch,  as  does  also  the 
head  of  cauliflower.  Celery,  seakale,  and  asparagus  are 
permissible  except  in  a  very  severe  dietary — as  are  also 
mushrooms.  French  beans  freed  from  seeds  may  also 
be  eaten  without  inducing  glycosuria.  Green  goose- 
berries and  rhubarb  stewed  and  sweetened  with  saccharin 
may  be  taken,  and  also  tomatoes,  cucumbers,  and  olives. 
The  greatest  difficulty  is  in  finding  a  substitute  for  bread. 
Perhaps  the  best  is  protein  or  casoid  made  from  milk, 
though  many  others  are  offered,  such  as  soya,  almond 
meal,  and  gluten. 

As  it  is  not  always  absolutely  necessary,  or  indeed 
possible,  to  entirely  exclude  carbohydrates,  Jerusalem 
artichokes  may  be  permitted  and  potatoes  may  some- 
times be  employed  in  place  of  bread,  containing  as  they 
do  about  half  as  much  starch.  Alcohol,  particularly 
in  the  form  of  spirits  and  unsweetened  wines,  may  be 
recommended. 

An  illustrative  diet  is  the  following  : 

Beef  or  mutton,  about  2  lb. 
Diabetic  bread,  3  oz. 
Green  vegetables,  9  oz. 
Potatoes,  2  oz. 
Fish,  5  oz. 
Cream,  3  oz. 
Butter  (fats),  3  oz. 
Cheese,  2  oz. 
Wine,  J  pint, 

such  a  diet  representing  about  3,000  calories. 

Nephritis  and  insufficiency  of  the  kidneys, 
wldch  interfere  with  the  removal  of  nitrogenous  waste, 
while  permitting  the  transudation  of  albumen,  require 


Nephritis  245 

special  consideration  in  regard  to  food.  A  milk  diet  is 
the  most  suitable,  skimmed  being  better  supported 
than  pure  milk  in  the  worst  cases,  to  which  may  be  added 
carbohydrates,  vegetables  and  fruits,  with  the  exception 
of  asparagus  and  cabbage.  In  less  severe  cases,  eggs 
and  even  meat  in  small  quantities  may  be  employed, 
pork  being  perhaps  best.  Elimination  of  salt  from  the 
diet  appears  to  lessen  the  transudation  of  albumen,  and 
to  reduce  the  oedema.  All  spices,  smoked  meats,  and 
alcoholic  liquors  should  be  forbidden.  A  strict  diet 
would  include 

5  pints  of  milk, 

6  oz.  of  bread, 
3  oz.  biscuit, 
IJ  oz.  cheese, 

corresponding  with  about  2,500  calories  per  day. 

Perhaps  the  most  frequently  occurring  cases  in  which 
diet  has  to  be  carefully  arranged  are  those  in  which 
ordinary  food  gives  rise  to  irritation  with  pain,  vomiting, 
and  diarrhoea  owing  to  a  disordered  state  of  the  mucous 
membrane  in  the  stomach  or  intestines,  possibly  attended 
by  actual  ulceration. 

The  object  to  be  kept  in  view  under  such  circumstances 
ia  maintenance  of  nutrition,  perhaps  only  approximate, 
for  a  time  by  the  administration  of  bland,  easily  digestible, 
and  highly  nutritious  food  in  small  bulk,  while  carefully 
excluding  aU  irritants  such  as  condiments,  alcohol,  and 
insoluble  matters. 

The  general  principle  being  the  same,  details  in  mode 
of  administration  necessarily  vary  according  to  the  site  of 
disease. 

When  it  is  necessary  to  avoid  acid  secretion  or  peri- 
stalsis in  the  stomach,  or  when  for  other  reasons  food 
cannot  be  introduced  into  the  digestive  tract,  nutrition 
may,  for  a  time,  be  maintained  and  thirst  allfiviated  by 
trans-  or  hypodermic  alimentation. 


246  Artificial  Feeding 

Cod-liver  oil  is  pretty  freely  absorbed  by  the  skin 
when  smeared  and  gently  rubbed  over  the  abdomen, 
the  part  being  subsequently  covered  with  a  flannel  binder, 
which  must  not  be  renewed  too  often,  as  it  is  an  advantage 
for  it  to  become  saturated  with  the  nutrient.  This 
method  is  usually  adopted  in  infants  suffering  from 
malnutrition  especially  in  association  with  tuberculous 
disease  of  the  peritoneum  or  intestines. 

In  a  more  definite  way  and  in  larger  quantity  solution 
of  glucose  5  ij  to  the  pint  or  normal  saline  solution  con- 
sisting of  water  with  -6  per  cent,  of  salt  or  bicarbonate 
of  soda  may  be  injected  under  the  skin  in  volumes  of 
a  pint  at  a  time,  and  sterilised  serum  of  the  sheep,  ox,  or 
horse,  or  olive  oil  may  be  administered  in  the  same  way 
in  about  one-fourth  the  amount. 

In  a  case  of  oesophageal  cancer  which  was  unsuitable 
for  gastrostomy  and  where  rectal  alimentation  had  led 
to  irritation  and  diarrhoea,  the  patient  actually  gained 
weight  under  treatment  by  hypodermic  injection  of 
broth.  Such  cases  are  fortunately  rare,  but  it  is  useful 
to  possess  some  means  of  sustaining  life  when  the  ordinary 
channels  of  nutrition  are  not  available.  When  it  is 
undesirable  or  impossible  to  give  food  by  the  stomach, 
recourse  may  generally  be  had  to  enemata,  which  may 
consist  either  of  plain  water,  normal  saline  solution,  or 
one  of  sanatogen  (a  teaspoonful  to  the  pint),  or  of  pre- 
digested  foods. 

In  any  case  enemata  should  be  administered  slowly, 
as  high  up  in  the  bowel  as  possible,  and  at  the  body  tem- 
perature ;  the  volume  too  should  not  exceed  ten  ounces  or 
at  first  even  five  ounces,  and  the  composition  should  be 
such  as  will  cause  no  irritation.  A  cleansing  enema  once 
a  day  is  necessary  in  addition. 

Continued  experience  in  cases  of  gastric  ulcer  with 
simple  water  injections,  commencing  with  five  ounces, 
raised  in  twenty -four  hours  or  less  to  ten  ounces,  and  given 


Enemata 


247 


every  four  hours,  has  sufficiently  proved  their  efficacy. 
The  advantages  are  simplicity  in  administration, 
complete  absence  of  irritation,  of  decomposition,  and  of 
the  foul  condition  and  ill-taste  in  the  mouth  which  are 
commonly  associated  with  the  use  of  nutrient  enemata  ; 
while  the  patient  approximately  maintains  weight  and  in 
gastric  ulcer  remains  free  from  hunger  and  thirst  till  the 
time  arrives  for  resumption  of  feeding  by  the  mouth, 
even  for  as  long  a  period  as  three  weeks — which  is  as 
much  as  can  be  claimed  for  nutrient  enemata. 

The  following  are  some   accepted  formulae  for  the 
latter : 


Peptone 
Milk     . 


3  Eggs. 
Common  Salt 
Milk      . 

Grape  Sugar . 
Milk      . 


Starch  (raw) 
Milk      . 


Bij 

3ix 


gr.  1 
Six 

5ij 

§ix 

Bij 


(^Leube) 

Wheat  Flour,  2  table-spoonfuls. 
Lukewarm  Water  or  Milk     .        g  v 
Common  Salt         .         ,         .  gr.  xv 
1  or  2  Eggs. 
15     per     cent.    Solution   of 

Glucose  ....    §ij-iv 
1  Glass  of  Claret. 

(Ewald) 


Milk      . 
Yolks  of  2  Eggs. 
Common  Salt        . 
Eed  Wine      .        . 
Starch  or  Arrowroot 

(Boas) 


Milk      . 
2  or  3  Eggs. 
Common  Salt 
Eed  Wine 


(^Riegel) 


Beef  Tea  or  Meat  Juice 
Yolks  of  6  Eggs. 
Common  Salt 
Red  Wine     . 

(^Tournier) 


3 IX 

gr.  XV 
Sss 

Bss 


gr.  XX 
Bj 


.       Bv 

gr.  XXX 

3j 


Owing  to  the  coagulating  effect  of  the  Bacillus  Coli 
on  casein,  efficient  cleansing  of  the  bowel,  and  even  the 
introduction  of  2  grains  of  benzo-naphthol  or  chloretone 
as  a  disinfectant,  is  very  necessary.  Alcohol  in  small 
quantity  and  salt  assist  absorption. 

When  the  digestive  capacity  of  the  stomach   com- 


248  Graduated  Feeding 

mences  to  be  restored  as  shown  by  the  subsidence  of 
local  symptoms  and  reawakening  of  appetite,  feeding 
by  the  mouth  may  be  resumed  by  slow  degrees,  fluid 
enemata  being  continued  at  first,  the  following  being  a 
suitable  sequence  of  foods  : 

Milk  and  Water  or  Soda  Water,  equal  parts  (peptonised  if  necessary). 
Albumen  Water  with  Salt. 
Whey  or  Buttermilk. 

An   ounce    every  hour,   increased    gradually   in    quantity    with 
extension  of  interval. 

Benger's  Food. 
Blancmange. 
Junket. 
Custard. 

Rusk  in  addition  to  milk,  which  may  be  fortified  with  one  of  the 
milk  or  meat  dry  extracts. 

Sheep's  or  Calf's  Brains. 

Oysters. 

Eggs,  in  addition  to  milk,  with  Beef  Tea  or  Soup. 


Tripe. 

Sweetbread. 

Boiled  flat  fish. 

Calf's  Head. 

Stewed  Sheep's  Tongue. 


Tea  made  with  boiling  Milk. 

Bread-and-butter,  or  dry  Toast. 

Milk  Gruel  or  Arrowroot. 

Chocolate. 

Milk  Puddings,  especially  Rice. 

Light  Wine  or  Champagne. 

The  more  easily  digestible  forms  of  ordinary  food 
carefully  cooked  may  follow,  if  there  has  been  no  set- 
back in  the  matter  of  pain,  vomiting,  nausea,  or  diarrhoea. 
It  may  be  useful  here  to  suggest  that  the  juice  of  pine- 
apple taken  in  small  quantity  at  the  end  of  a  meal  is  an 
agreeable  and  powerful  digestive  agent. 

This  gradation  in  diet  may  be  usefully  followed  in 
convalescence  from  fevers  and  other  severe  illness,  but 
is  specially  appropriate  to  gastric  diseases  and  to  cases 
after  operations  on  the  stomach,  being  adapted  to  en- 
feebled digestive  power.  As,  however,  such  diet  is 
.selected  with  a  view  to  avoiding  bulky  and  indigestible 


Limitations  of  Milk  Diet  249 

residues,  it  is  also  suited  to  disease  of  the  small  and  large 
intestine  in  which  mechanical  or  chemical  irritation 
has  to  be  avoided.  In  this  respect  the  adoption  of  a 
purely  mUk  diet,  especially  when  quantities  are  given 
exceeding  three  pints  in  the  twenty-four  hours,  is  open 
to  criticism,  as  it  may  often  be  found  that  such  a  regime 
tends  to  the  escape  of  considerable  amounts  of  undigested 
casein.  This,  apart  from  waste,  may  cause  unnecessary 
irritation  throughout  the  digestive  tract.  The  white 
curd  is  easUy  detected  in  the  fseces,  and  is  commonly  seen 
in  infants  and  in  cases  of  typhoid  fever,  sometimes 
associated  with  constipation,  but  more  often  with  diarrhoea. 

The  idea  that  milk  feeding  involves  a  fluid  diet  is  a 
superficial  error,  since  the  proteid  constituents  which 
form  the  curd  of  milk,  when  this  is  taken  in  the  crude 
state,  are  apt  to  traverse  the  digestive  tract  in  a  solid 
and  by  no  means  easily  absorbed  form. 

Even  in  the  treatment  of  typhoid  fever  in  which  an 
exclusive  mUk  diet  has  had  so  long  a  sway,  the  practice 
is  being  departed  from,  though  this  objection  may  be 
met  by  dilution,  reducing  the  quantity  given  or  by 
predigestion.  As  has  been  mentione-d  elsewhere,  the 
addition  of  lime-water  lessens  the  density  of  the  curd, 
and  may  be  obtained  in  an  aerated  form  in  syphons. 


FORMULiE 


FUNCTIONAL  DISTURBANCE  OF  LIVER  (pp.  i-io) 

Pil.  Hydrarg.          . gr.  iij 

Ext.  Hyoscyam gr.j 

Ext.  Aloes gr.  j 

M.  ft.  pil 


The  Quarter-grain  Pill 

Enonymin 1 

Podophyllin -  ^a  gr-  J 

Iridin J 

Extract!  Taraxaci q.s. 

Calomel  gr.  \  may  be  added 

M.  ft.  pil. 


Black  Draught 

Magnesii  Snlphatis 5]'ss 

Ext.  Glycyrrhiz.  Liq rn.  xxiv 

Tincturse  Sennce 3  J 

Tinct.  Cardam.  co 11  xxxvj 

Inf  usum  Sennae ad  5  j 

To  be  taken  in  the  morning. 


For  Bilious  Indige 


Sodse  Salicylatis 
Succi  Taraxaci 
Sodse  Sulphatis 
Sp.  Am.  Aromat. 
Sp.  Chloroformi 
Infusum  Gentianse 

Three  times  a  day  before  meals. 
250 


tion 


gr.  X 

5ss 
3ss 

Xtl  XX 
Til  X 

adgj 


Formulae 

Stimulant  Draught 

9.     Ammonii  Carbonatis      ...                 , 
Lactis     , 

gr.  x-xxx 
Oss 

251 


Bile  Stimulant 

^.     Podophyllin.  ResinaB      ...                 , 
Glycerini 

3  j  at  intervals  of  2-4  hours. 


FLATULENCE  (pp. 


^.     Sp.  Am.  Arom. 
Sp.  Chloroformi 
Tinct.  Carminative 
Aquam    . 


9.     Sp.  Am.  Arom.        . 
Sp,  Chloroformi 
Sodae  Bicarbon. 
Infusum  Caryophylli 


9.    Menthol. 
Calomel . 
Pulv.  Zingiberis 
Maltine  . 


10-15) 


3ss 

Til  XX 

ITl  X 

adSJ 


HI  XX 
Til  X 

•      gr.  X 
.    ad5j 


•      gr.  I 

.     gr.  ij 

q.s 


M.  ft.  pil. 
One  to  be  taken  every  quarter  of  an  hour  till  relief  is  obtained. 


Emergency  Prescription  for  Flatulence 

Pour  a  wine-glassful  of  boiling  water   on  5  crushed   cloves  and  add 
20  grains  of  Bicarbonate  of  Soda. 


Enema  Terebinthinae 


T)i.     Olei  Terebinthinse  . 
Mucilaginis  Amyli . 


53 
Bxv 


'^.    Olei  Terebinthinse gss 

Bnema  Saponis      .  .....       0  ss 


Enema  Asafetidae 

^.    Asaf etidae .  gr.  xxx 

Aq.  destillat.  .  ,        .  ....        §  i^ 


252  Formulae 


Enema  Rutae 

5;.    Olei  Eutse ni  :!fxx 

Mucilag.  Acacias     ....  •        •        •        3ij 

Enema  Simplex      .        .        .        .        .        .        .        .  ad  5  vj 


ACIDITY  AND  HEARTBURN  (pp.  15^17) 

]^.    Magnesii  Oxidi 

Sodii  Bicarbonatis 

Sodii  Phosphatis ^aaBss 

Sacchari  Albi 

5  j  at  intervals  of  half  an  hour  or  of  tenet. 


For  Hiccough 

Chloretono .     gr.  v 

In  Gelatine  capsule. 


FOR  REMOVING  SCYBALA  (p.  31) 

^i.    01.  Crotonis .        .        .      gr.  -I 

Pulv.  Zingiberis gJ".  ij 

Maltlne q.s. 

M.  ft.  pil. 
1  or  2  three  times  a  day. 


FOR  CRACKS  ON  THE  LIP,  FINGER,  OR  NIPPLE  (p.  32) 

Hebra's  Lotion 

]^.    Ac.  Carbolici 3  iJ 

Glycerin! gj 

Etheris gj 

Sp.  Vin.  Rect.        .        .                gvj 

Ft.  lotio. 

^.     Plumbi  Acetatis ,        .  gr.  xv 

Adipis  prseparatEe  .        ...■.,.  gj 
M.  ft.  ung. 

CATARRHAL  HERPES  (p.  33) 

9i.     Zinci  Oxidi g  j 

Acidi  Borici g  ij 

Amyli giij 


Formulae 


253 


PEPTIC  ULCER   (p.  36) 

Acid  Nitro-Hydroch.  dil "l  x 

Liq.  Strychninse '"l  iv 

Sodii  Sulphatis 5  ss 

Aq.  Chlorof ormi .        .  ad  5  j 

Tliree  times  a  day  after  food. 


MOUTH   WASH   (p.  36) 

Resembling  Odol 

9.     Salol 

Saccharin       .  .        .  .        • 

01.  Menth.  Pip.       .        .  ... 

Alcohol  (80%) 

Add  oils  of  Clove  and  Caraway. 


2-5     parts 

•004      „ 


97 


Resembling  Glycothymoline 


9- 


Thymol 
Acid  Benzoici 
Olei  Gaultherii 
Eucalyptol 
Olei  Menth.  Pip. 
Spir.  Vin.  Pvcct. 
Acidi  Borici    . 
Glycerini 
Tincture  Cocci 
Aq.  destill. 


gr.j 
gr-j 

mss 

gr.  ss 
3J 

gr.  XXV 

3J 

TH,  XX 

adOj 


REMEDY  FOR  TOOTHACHE   (p.  4O 

Tincturae  Aconiti .39 

Linimenti  lodi 3ij 

Chlorof  ormi 5ij 

To  be  rubbed  on  the  gum  after  drying. 


Odontodol  for  Toothache  (p.  42) 

^.     Cocain.  Eydrochloratis gr-  xvj 

Acid.  Hydrocyan.  dil "1  xvj 

Tincturae  Amicse 3  ij 

Liq.  Am.  Acetat ad5j 

To  be  applied  to  the  tooth  cavity  or  rubbed  on  the  gum. 


154 


Formulae 


KEMEDffiS  FOR  LOSS  OF  HAIR   (pp.  54  5) 

LOTIONS 

Erasmus  Wilson 

^.     01.  Amygdalss •  5  j 

Liq.  AmmoniEe oj 

Eau  de  Cologne §  j 

01.  Eosmarini 3  iij 

01.  MyristicaB 3  i^ 

Tinct.  Jaborandi 3j 

Aq.  Eosse adgviij 


Hebra 


Tinct.  Canthar. 

(or  Ac.  Tannici 
Sp.  Vin.  Eectif. 
Sp.  Lavandula 
Ether.  Sulphurat. 
Glycerini 
01.  Bergamot . 


Tanno-Quinine 


Quin.  HydrochL 
Acidi.  Tannici 
Alcohol.  (60  %) 
Tinct.  Cantharid. 
Glycerini 
Eau  de  Cologne 
Vanilin   . 
Ligni  Santali . 
Pilocarpin.  Nitrat 

Mix,  macerate  i  d 


5  S3 

gr.  xij) 

5v 

5j 
5ij 
3iv 

Til  X 


gr.  XXIV 

3J 

gxss 

3J 

5vj 

3iv 
gr.  ss 
gr.  iij 
gr.  iv 


ays  and  filter — (osij). 


POMADES 

Tanno-Quinine 

Olei  Theobromi 5Js8 

Ung.  Emollient 5ss 

01.  Amygdala §  jss 

Quin.  Sulph.  dissolved -with  acid gr.  x 

Aq.  Eosae .        .        .  gss 

01.  Citri 5  S3 

01.  Bergamot lU  xx 

01.  Lavandulas "l  xx 

Ac.  Tannici gr.  xl 

Tinct.  Cantharid 3J 

Eau  de  Cologne 5  iiJ 


Formulae  ^SS 


Duputrcn 

l^i.     Medullas  Ossium ,        .        •  5ij 

Extracti  Cinchons3 51] 

Tinct.  Cantharid 3j 

Succi  Citri 3  J 

Olei  Limonis in,  xx 

"  Olei  Bergamot iri  x 

Gcmmarum  Populi 

I^.     Eesin.  Gem.  Populi         .        .         .....  gj 

Adip.  praeparatse gvj 

Aq.  Eosae tti  clx 

Heat  together  and  add 

Olei  Citri -v 

Olei  Bergamot [-  aa  tri  x 

Olei  Eosmarini J 


FRECKLES    (p.  69) 
Unna's  Formula 

9-     Bismtithi  Oxychloridi gj 

Calomelanos gr.  J 

Hydrogen,  Peroxid.  (10  vol.) §j 

Adipis  Lans  et  Vaselini aa  3  iv 

Ft.  ung. 

5;.     Bismuthi  Trinitratis 39 

Hydrarg.  Ammoniati 3  ij 

Adip.  prseparatae §j 

To  be  spread  on  lint  and  laid  on  the  patches  at  night 

Aqua  Cosmetica  Orientalis 

]^.     Hydrargyri  Perchloridi ,  gj 

Aquas  destillatEe      .        .        .        .        .        .        .        .  giv 

Ovorum  xxiv  Albumen 

Succi  Citri  (i.e.  Mal»  Med.)  .        ,        .        .        .        .  5  iij 

Sacchari  Albi §  viij 

REMEDIES   FOR   CHILBLAINS  (pp.  75-76) 
Dusting   Powders 

5i.     Acidi  Borici 50  parts 

Taici  Purificati .        .  25    „ 

Amyli ...  25    „ 

Camphor  vel  Menthol  j:!:r.  xv  in  g  j 


2^6  Formulae 


5;.     Calamine 7  parts 

Menthol .1  part 

Unguentum 

5..     Olei  Gaultherii 5  ij 

Menthol gr.  xv 

Adip.  Lanse 5j 

Lotio 

^.     Plumbi  Acetatis     . gr.  xvj 

Alcohol  (90  %)  (or  Eau  de  Cologne)      .        .        .        .  §j 

(Saturated  Solution) 

Lotio  Plumbi  Spirituosus 

^.     Liq.  Plumbi  Subacet.  fort 1  part 

Glycerin! 2  parts 

Alcohol.  (90  %)       .                  .  4    „ 

Aq.  Eosse 25    „ 

Bath 

^.     Aluminis 5ij 

Aq,  Calid Cj 

Steep  Chilblains  for  5  minutes. 

ty.     Liq.  Plumbi   ....  •        .        ■        •         S  j 

Tinct.  Opii 5  J 

Glycerin! §j 

Aquam adgviij 

To  be  applied  on  lint,  covered  with  protective. 

FOR  BSOKEN   CHILBLAINS 
Unna 

5i.     Eesorcin.  vel  Ichthyol 5  parts 

Acid.  Salicj'lici 3    „ 

Paraffin!  Mollis       .......         100    „ 

Ft.  ung. 

Carbolic  Acid  in  Vaseline      ......        5% 

REMEDIES   FOR   WARTS  (p.  78) 

^.     Magnesii  Sulphatis         ....  .        ,       5  ss 

Aq.  Menth.  Piperitas §j 

Three  times  a  day  for  adults,  5  j  for  children. 

^1.     Acid.  Nitro-Hydrochlor.  dil.  .  .     til  xy 

Aq.  Chloroform!     ....  ^1 

After  meals  three  times  a  day. 


9. 


Formulae 

Tinct.  Thuyse  Occidentalis "l  xxx-lx 

Ext.  Glycyrrhiz.  Liq 3  ^^ 

Aquam ^^SJ 

Three  times  a  day. 

LOCAL   KEMEDIES  (p.  79) 
Nitric  Acid  Caustic  Soda 

Acid  Nitrate  of  Mercury  Chromic  Acid 

Liquefied  Carbolic  Acid  Glacial  Acetic  Acid 

Sodium  Ethylate  Liquor  Ferri  Perchloridi  fort. 

Caustic  Potash  Liq.  Plumbi  Subacetatis  fort. 

Saturated  Solution  of  Salicylic  Acid  in  Alcohol. 


257 


Sulphuris 
Glycerini 
Acidi  Acetici 


Kaposi's  Solution 


To  be  applied  daily. 


5v 

3is8 

3ijs3 


9- 


CORN   CURE  (p 


Acidi  Salicylici 
Ext.  Cannab.  Ind. 
Alcohol.  . 
Etheris   . 
CoUodium  Flexile 


80 


gr.xv 
gr.  viij 

in,  XV 
mxj 

adSij 


Inflamed  Corn 
Apply  a  wet  compress  or  pad  steeped  in  Lotio  Plumbi  c  Opio. 


^■ 


RHEUMATIC   SORE   THROAT    (p.  92) 

Sodii  Salicylatis ..  gr.xv 

Potassii  Citratis gr.xv 

Olei  Limonis ^  ^ 

Sp.  Chloroformi '^  ^ 

Aquam ^"^^^ 

Every  four  hours  for  an  adult. 


GARGLES   FOR   SEPTIC   SORE   THROAT    (pp.  93-96) 


'^i.    Hydrarg.  Perchlor. 
Acid.  Hydrochlor.  dil. 
Glycerini 
Aquam  destillat. 


3ij 
5j 

adgx 

17 


258 
9. 


9. 


Formulae 


Potass.  CUoratis    .  . 

Acid.  Hydrochlor.  .  • 

Aquam   .        .  •        « 

Potass.  Permang.  ,  • 

Aqnam  .  .        t 

Formalin  Solution  (40  %) 
Aquam 

Acetozone.    Saturated  Solution  in  Water 
MIXTURES 


Potass.  Chloratis 
Acid.  Hydrochlor. 
Quin.  Sulphatis 
Syrupi  Aurant. 
Aquam   .        . 


5j  every  three  hours. 


5i 

itixij 
adgx 

gr.  iv 
Oj 

iti  X 
adgx 


gr.  s  to  0  j 


5SS 

5J 
gr.  xxxvj 

§j 
.  ad  3  xij 


Liq.  Ferri  Perchlor. 
Sp.  Chloroformi 
Glycerin! 
Aquam  destillat.     . 


Three  times  a  day. 


Liq.  Hydrarg.  Perchlor. 

Potassii  lodidi        ..... 

Sp.  Am.  Arom 

Decoct,  Cinchona  .  ... 

Three  times  a  day. 


Itl  XV 

HI  X 

ni  XX 
adgj 


33 


gr.  V 

ttl  XX 

Bi 


9. 


Liq.  Ferri  Perchlor ,        ,  itl  xv 

Liq.  Hydrarg.  Perchlor.          .                 .        .        .        .  tn,  xv 

Liq.  Strychninse      ...                 ....  in.  v 

Tinct.  Aconiti in,  iij 

Potassii  Chloratis gr.  v 

Glycerin!        . 3j 

Aquam  destillat .        .  ad  §  j 

Three  times  a  day. 

Tinct.  Nucis  Vom it  v 

Tinct.  Cinchonae  co 5  ss 

Sp.  Am.  Arom tn,  xx 

Aquam  Chloroformi       .        .                 .                 .  ad  §  j 
Three  times  a  day. 


Formulae 


259 


9. 


9. 


REMEDIES   IN   CA 

.TARR 

H   (pp.  97-ioj 

i) 

Terebene 

1 

01.  Bucalypti 



■55  3ii 

Camphor.        .         , 

Menthol . 

3-6  m  for  inhalation. 
COLLUNARTA 

Basis 

With  either 

Sodii    Bicarbon. 

vel 

Hazeline  . 

m  XX 

Sodii  Biboratis 

■     gr-  iv 

Alum 

gr.  V 

Aquam      ,        . 

.    ad5j 

Liq.  Pot.  Perm. 

m  vj 

Quin.  Sulph.     . 

gr.| 

Zinc  Sulph.      .         . 

gr.l 

Menthol  .        .        . 

gr-i 

Dobell's  Solution 

Gljcerini  Acid.  Carbol 

tnx 

Sodii  Biboratis 

gr.vj 

Sodii  Bicarbonatis 

gr.vj 

Aquam    . 

Linctus 

ad§j 

Tinct.  Camph.  co. 

^ 

Oxymel.  Scilte 



aagss 

Succi  Limonis 

J 

3  j  to  be  taken  frequently. 

Vin.  Antimon. 

, 

in  X 

Vin.  Ipecac.    . 

■         . 

. 

itix 

Sp.  ^th.  Nitros. 

•         •          • 

. 

5ss 

Liq.  Am.  Acet. 

,          ,         ,          . 

• 

3ij 

Syrup.  Limon. 

.          . 

. 

3j 

Mist.  Amygdal. 

Every  four  hours 

• 

ad5i 

Ammon.  Carb. 

•        •        •        < 

.       • 

gr.v 

Tinct.  Camph.  co.  . 

. 

. 

III  XX 

Syrup.  Scillge  . 

.        .        .        • 

. 

3ss 

Syrup.  Tolu.    . 

•        •        •        • 

•             •              • 

3J 

Infus.  Senega 

Every  four  hours 

• 

ad§j 

Vin.  Ipecac.    . 

•        •        •        • 

•       •       • 

3ss 

Tinct.  Scill^  . 

.        • 

. 

3ss 

Sp.  Am.  Arom. 

>        •        •        • 

•       •       • 

3ss 

Glycerini 

•        •        •        • 

. 

3j 

Aq.  destillat. 

. 

. 

. 

adgjss 

3j-ij  every  four  hours  for  children. 


26o 


Formulae 


PLEURODYNIA    (pp.  107-110) 

Tinct.  Ferri  Perchloridi iti  x 

Liq.  Arsenic.  Hydrochlor. tti  v 

Glycerini 5ss 

Aq.  Chlorof  ormi ad  5  j 

Three  times  a  day. 


aa  gr.  x 


Sodii  Salicylatis 

Sodii  Bromidi ,        , 

Phenazoni       

Aq.  CamphorBe acl5j 

Three  times  a  day. 


HYPNOTICS  (pp.  113,  114) 

Morphini gr.  i 

Atropini gr.  ^^^ 

Strychnini gr.  -^ 

Aquam   ..........       ni_  yj 

tn,  iij-vj  for  hypodermic  injection,  particularly  in  cardiac  cases. 


Potassii  Bromidi    . 
Sodii  Bromidi 
Ammon.  Bromidi    . 
Acid.  Hydrocyan.  dil. 
Sp.  Am.  Arom. 
Sp.  Chloroformi 
Aq.  Menth.  Pip. 

The  draught  to  be  taken  at  night. 


aa  gr.  x 

miij 
tri  XX 
in,  XX 
adSj 


Potass.  Bromidi gr.  xx 

Chloral.  Hydratis gr.  xv 

Tinct.  Cannabis  Indie nx  x 

Mucil.  AcaciEe gj 

Aq.  Chloroformi ad  g  j 

The  draught  to  be  taken  at  night. 


HEADACHE  (pp.  126-143) 

^.     Liq.  Trinitrini ni^  ij 

Acid.  Hydrobrom.  dil iri  xx 

Aquam §  ss 

Twice  with  half  an  hour  interval  at  the  onset  of  migraine. 


Phenacetin.    . 
Caffein.  Citrat. 


gr.  X 
gr.  V 


Formulae 


261 


^.     Phenacetin gr.x 

Butyl  Chloral gr.  s 

'^.     Antipyrin.      . gr.x 

Caffein.  Citrat.        .        .        .        .        .        .        .        .  gr.  v 

In  cachet  or  powder. 

^.     Phenazoni "j 

Sod.  Salicylat 1-  aa  gr.  x 

Am.  Bromidi J 

Aq.  Camph ad  §  j 

Every  two  hours  till  four  doses  have  been  taken. 

5.     Quin.  Muriat gr.  ij 

Tincturse  Guaranse         . 5  ss 

Acid.  Hydrobrom.  dil m  xx 

Aqaam  Chloroformi ad  §  j 

Threa  times  a  day  before  meals. 

9.    Butyl  Chloral gr,  ii] 

Gelseminini  Hydroch gr.  -^ 

Glycerini  Tragacanth q.s. 

M.  ft.  pil. 


Pot.  Bromidi  . 
Tinct.  Valerian.  Am. 
Aq.  Camphoras 


gr.xx 

3J 
adBj 


Headache  in  Anaemia 

Sodii  Salicylatis gr.  xx 

Ferri  et  Am,  Cit,    .        . gr.  v 

Sp,  Am.  Aromat gr.  xxx 

Aq,  Chloroformi  ad  §  j 

Three  times  a  day. 


Tinct.  Ferri  Perchlor 

Liq.  Arsenici  Hydrochl.         ..... 

Glycerini 

Aquam  destill 

Three  times  a  day  after  food. 

Headache  with  Digestive  Disturbance 
Succi  Taraxaci 
Sod.  Sulphatis 
Tinct.  Nucis  Vom. 
Sp.  Am.  Aromat, 
Aq,  Chloroformi 

Three  times  a  day  before  food. 


vi  X 

m  V 

5  S3 

adSJ 


3ss 

3ss 

in,  V 

in,  XX 

ad  §3 


262 


Formulae 


Headache  with  High  Arterial  Tension 
Potassii  Citratis     . 
Liq.  Ammonii  Acet. 
Sp.  Ether.  Nitros.  . 
Aq.  Laurocerasi 
Aquam  Camphorse  . 


Three  times  a  day. 


Pot.  lodidi     .        , 
Pot.  Bromidi  . 
Acidi  Hydrobrom.  dil. 
Aq.  Camphorse 


Three  times  a  day. 

Headache  with  Low  Arterial  Tension 

Tinct.  Nuc.  Vom 

Tinct.  Quin.  Ammon.     .  .... 

Tinct.  Aurantii 

Aq.  Chloroformi 

Three  times  a  day  before  meals. 


gr.  XV 
3ij 

3S3 

3i 

ad§j 


gr.  11] 

gr.  XV 

ITl  XX 

adSj 


ni  V 

3J 

•3J 

adiSj 


REMEDIES   IN   SEA-SICKNESS   (pp.  145-146) 

1^.     Pot.  Bromidi ^ 

Am.  Bromidi .        .        .        .        .        .        .        .       |-  aa  gr.  xx 

Sod.  Bromidi ........  J 

To  be  taken  in  J  pint  of  Soda  Water. 

Chloretone  gr.  v  in  gelatine  cachet. 

^.    Morphini  Tartarati  .        .        ,        .        ,        ,      gr.  J 

Atropinas  Sulphatis       .        .  .        .        ,        •  gr.  ^j 

TONIC  (pp.  151-154) 

^.    Tinct.  Nucis  Vomicas ,  iri  v 

Tint.  Cinchonse  co 5  ss 

Sp.  Am.  Aromat ,        .  fii  xx 

Tinct.  Aurantii 5  3s 

Aq,  Chloroformi ad  5  j 

Three  times  a  day  before  meals. 

EPISTAXIS   AND    OTHER  H/EMORRHAGE  (p.  160) 
1^.     Calcii  Chloridi       ...  .  .        .    gr.  xx 

Syrupi  Aurantii 3  ]' 

Aquam    ...  .  .        •        •        •    ad5j 

Three  times  a  day. 


Formulae 


263 


9     Magnesii  Carbonat.  levifl 

Magnesii  Sulphatis         . 
Aq.  Menth.  Piperit. 


5] 

3j 


FIBROSITIS   AND   MYALGIA    (p.  172) 

^.     Sodii  Sulphatis 5  ss 

Pot.  lodidi gr.  V 

Sodii  Salicylatis      .         .         .        ,         ,        .        .        .  gr.  x 

Extract.  Glycyrrhiz.  liq 5  ss 

Aquam            ...                         ....  ad  3  j 


9- 


REMEDIES   FOR    THE   EYE   (pp.  174-176) 
LOTION    FOE    STYES    (p.  56) 

Sodii  Bicarb.  . 
Boracis    . 


Acid  Hydrocyan.  dil. 
Aq,  Sambuci  . 
Aq.  destillat .         . 


3J 
3J 

3  S3 

.       3ij 

ad  5  -yiij 


Cocain.  . 
Olei  Eicini 


LOCAL   ANESTHETIC 


gr.  X 
5j 


9- 


OINTMENTS   (p.  177) 


Ung.  Hydrarg,  Nit. 
Vaselin.  Alb.  . 


Acidi  Borici 
Vaselin  Alb. 


3i 

adgj 

3j 
adgj 


Hydrarg.  Oxidi  Flav. 
Paraffin!  Mollis 


gr.  iv-vu] 

3j 


COLLYEIA  (p  175) 


Acid.  Borici. 
Aq.  destillat. 

Sodii  Bicarb. 
Aq.  destillat. 

Boracis  . 
Aquam  dest. 

Hazeline 
Aquam  dest. 


■        •        • 
ft        •        • 


.  gr.x 
adSj 

.  gr.  XV 

.  adSJ 

.  gr.x 

.  5j 

.  m  XX 

.  adgj 


264  Formulae 

^i.     Zinci  Chloridi *        •        .        .   gr.  ss 

Aquam  dest.     .        .        . adgj 

5i.    Acetozone ,        ,        .gr.  J 

Aquam  dest ad  §  j 

Saturated  watery  solution  filtered  after  standing  4  houra. 


SOLUTIONS   FOR    SINGLE   APPLICATION 


Arg.  Nitratis . 
Aq.  destillat. 


.    adgj 


Protargol gr.  xv 

Aq.  destillat adgj 


THE   EAR   (pp.  180-181) 


^■ 

Acidi  Borici 

Aq.  destillat.  ...                 ... 

.    gr.  X 

^■ 

Argent.  Nitratis      .        ,        .        . 

Aq.  destillat.   .        .                 .... 

gr.  XXX 

^• 

Hydrarg.  Subchlor 

Adipis  pr^parat.      .,,... 

.       3j 

9. 

Hydrarg.  Ammon 

Paraffin.  Moll. 

.  gr.  XX 
.       .       5j 

^. 

TJng.  Hydrarg.  Nit.          .        •        «        . 
Vaselini  Alb 

.       .      3J 

^. 

Tinct.  Opii 

Tinct.  BelladonnEe 

Sol.  Cocainse  Alcoholic 

I   p.  seq. 

^■ 

Sodii  Bicarb 

Glycerini 

Aq.  Posse 

Liq.  Hydrarg.  Perchlor.  1-1000 

.  gr.  XX 
•        5j 
.  adgj 

^- 

Calcii  Hypochloritis 

Aquam  destill.         ,*,»>> 

.    gr.ij 
.  adgj 

w 


Formulae  265 


;^.     Sodii  Hypochloritis gr.  iv 

Aquam  destillat adgj 

REMEDIES   FOR   NOSE    (p.  183) 
Lotio  Sulphufis  c,  Sapone 

9.    Saponis  Mollis gr.  ^ 

Sulphur,  prsecipitat gr.  xxx 

Eau  de  Cologne 3  J 

Glycerin! m  v 

Aq.  Eos» 5j 

Ung,  Sulphuris 

^.     Sulphuris  Sublimati 5  j 

Adip.  Benzoat 3i^ 

FOE    HAY    FEVER    (p.  184) 

^.     Cocaine gr.  j 

Sol.  Adrenalin.  1-1000 3  J 

COLLUNAEIA    (pp.  184-185) 

Dobell's  Solution,  etc.  (see  p.  260). 

3  per  cent.  Solution  Peroxide  of  Hydrogen. 

Acetozone,  Saturated  Watery  Solution. 

NEBULA   (p.  186) 

9.    Thymol gr.  x 

Petrol.  Liq 5j 

]^.    Camphor  , 'I 

Menthol  .  I         iz-- 

Terebene ^   aa3i] 

Eucalyptol J 

GENITO'URINARY  SYSTEM  (p.  188) 

FOR    VDLVO-VAGINITIS 

^.     Zinci  Sulphatis gr.  v 

Aq.  destillat.  .        ,        ,        , ad  §  j 

"^     Aluminis         .        •..,..        ..gr.  v 
Aq.  destillat.  ,  ,  ,        ,        ,        ,        ,    adgj 


2^6  Formulae 

Lot.  Sulphatura 

9.     Zinci  Sulphatis        ....  .        ,         gr.  xxx 

Aluminis gr.  xxx 

Ferri  Sulphatis gr.  xx 

Cupri  Sulphatis        ,         ,        .        .         .         ,        ,         .     gr.  ij 
Aquam adgviij 

ENURESIS  (p.  188) 

9.    Tinct.  Lycopodii 5ss 

Syrupi  Aurantii       ...  .         .         .         .     ni  xx 

Phenazoni        .        , gr.  v 

Aquam .        ,        .adgss 

Before  bedtime. 

DYSURIA  (p.  190) 

]^.     Tinct.  Hyoscyami .        ,      3  ss 

Sodii  Bromidi  .  gr.  x 

Acid.  Hydrocyan.  dil ni  iv 

Infusum  Buchu adgj 

Three  times  a  day. 

]^     Ammon.  Benzoatis gr.  x 

Tinct.  Hyoscyami .  5ss 

Pot.  Bromidi    .        .                 .        .                 .        .        ;  gr.  x 

Infusum  Buchu .  ad  §  j 

Three  times  a  day. 

MENSTRUATION  (p.  191) 

AmmoDol,        • :     gr.  v 

In  Tabloid. 

Chloretone gr.  v 

In  Gelatine  Cachet. 

CLIMACTERIC  NEUROSES  (p.  192) 

9.    Tinct.  Valer.  Am.     .......  .        3  j 

Pot.  Bromidi  .        .        . gr.  xv 

Aq.  Camphorae .        .  adgj 

Three  times  a  day. 

Ichthyol .    gr.  V 

In  pil.  three  times  a  day. 

STIMULANT  MIXTURE  (p.  232) 

^.     Tinct.  Aurantii 3  iJ 

Sp.  .Etheris 5  ss 

Sp.  Am.  Aromat.     .        , ,5ss 

Tinct.  Nucis  Vomicae "l  x 

Aq.  Chloroformi adgj 


Formulae  267 


INFANTS  (pp.  194-198) 
STOMATITIS 
Glycerin!  Boracis. 

^.     Potass,  permanganatis    .        ,        ,        .         .        ,        ,gr.  v 
Aq.  destillat 5j 

^.     Acid.  Borici ,        .        .  gr.  xv 

Aq.  destillat •        •        Sj 

Lapis  Divinis 
9.     Cupri  Sulphatis       .......      ^ 

Aluminis j-  p,  seq. 

Potass.  Nitratis J 

Fused  together. 

DIAllRHCEA  IN  INFANTS  (pp.   195-196) 

^.     Sodii  Bic gr.  iij 

Pulv.  Ehei gr.  vj 

Pulv.  Zingib gr.  j 

For  a  child  up  to  two  j-ears. 

'^.     Sod.  Bicarb gr.  ij 

Bismuth.  Carbon gr.  jss 

Pulv.  Tragac.  co gr.  j 

Sp.  Chloroformi      . til  jss 

Aq.  Cinnamomi  ad  3  j 

Every  2-4  hours. 

Bism.  Subgallatis gr,  ij-v 

In  place  of  Bism.  Carbon.,  if  Diarrhoea  continues, 

]^,    Ext,  Hsematoxyli    .        , gr,  ijss 

Tinct.  Catechu itl  v 

Syrupi  Tolu irv  x 

Aq.  Cinnam.    .        « ad5j 

Every  4  hours. 

CONSTIPATION  (p.  197) 

]^.     Tinct.  Belladon tti  v 

Tinct.  Nucis  Vom .  ri  ss 

Syrupi  Sennae ni  x 

Inf.  Gentian  co ad  3  j 

Three  times  a  day  for  a  child  of  three  or  four, 

COLIC   AND  FLATULENCE   (p.  198) 

9.     Mag.  Carb.       .        .        , gr.  jss 

Pulv.  Ehei.  gr.  J 

Syrup.  Zingib. tn,  v 

Aq.  Menth,  Pip ad3j 

Every  2  hours. 


INDEX 


Abdominal  Massage,  47 
Acanthosis  Nigricans,  78 
Acetanilid,  118,  131 
Aceto-Pyrine,  133 
Acetozone,  185 
Acne  Rosacea,  182 
Actinic  Melanoses,  69 
Adenoid  Growths,  184 
Adrenalin  in  Epistaxis,  159 
Alcohol  as  a  beverage,  224 

in  Delirium,  230 

and  Digestion,  223 

with  Digitalis,  232 

efiects  of,  225 

as  a  food,  226 

complete  Oxidation,  231 

as  a  stimulant,  226,  231 

and  Soporifics,  225 

Ale  as  a  beverage,  227 
Alimentation  by  Skin,  245 
Alkaline  Waters  in  Bilious  Attack, 

7 
Alopecia  Furfuracea,  53,  55 
Alveolar  Abscess,  42 
Ammonol,  191 
Anal  Veins,  dilatation  of,  9 
Anaemia,  136 

and  Debility,  150 

and  Headache,  120 

and  treatment  of,  137 

Anasarca,  5 

Ant,  wound  made  by,  58 
Anti-Neuralgics,  133 
Antipyrin  in  Neuralgia,  133 

as  a  Hypnotic,  114 

Caffeine  Citricum,  127,  133 


Antipyrin  Salicylate,  135 
Anus,  fissure  of,  43 
Aphthous  Stomatitis,  37 

Vulvitis,  188 

Appetite,  loss  of,  3 
Arbor  Vitae,  for  Warts,  79 
Arterial  Tension  and  Sleeplessness, 

114 
Arum     Lily     Bulbs,     rash     from 

handling,  65 
Ascites,  5 
Aspirin,  135 
Asthma,  27 
Atrophic  Rhinitis,  184 

Bacillus  of  Smegma,  186 

Balanitis,  186 

Baldness,  49 

Ballooning  of  Rectum,  25 

Bathing,  203 

Baths,  Hot,  in  Liver  Chill,  10 

Bednar's  Aphthae,  193 

Beef  Cakes  in  Obesity,  241 

Bees,  stings  of,  59 

Bile  Circulation,  4 

Resorption,  4 

Biliary  Fistula,  4 
Bilious  Attack,  2 

treatment  of,  6 

Bites  of  Insects,  58 

Black  Bean,  poison  from,  66 

" Eye,"  170 

Blepharitis,  176 

Blisters,  84 

Blood  Coagulability,  71 

Pressure,  variation  in,  154 


Index 


269 


Blue-stainlng  of  Feet,  86 
"  Blues,  The,"  8 
Boils  in  Ear,  180 
Borborygmi,  13 
Bottled  Ale  as  a  beverage,  227 
Brandy  as  a  beverage,  229 
Broken  Chilblains,  76 
Bromides,  113 

in  Sea-sicliness,  145 

Brow  Ague,  121,  129 

Bruises,  170 

Bulbs,  rash  from  handling,  65 

Bunion,  82 

Bursitis,  169 

Buttercups,  rash  from  handling,  66 

Buttocks,  pimples  on,  57 

Butyl  Chloral  as  a  hypnotic,  114 

in  Neuralgia,  133 

Cactein  Fillets,  158 

Caffeln,  133,  134 

Callosities,  80 

Cannabis  Indica,  133,  134 

Caput  Succedaneum,  194 

Carbonate  of  Ammonia  in  Bilious 

Attack,  7,  10 

in  Headache,   142 

Cardiac  Overstrain,  159 

Caries  of  Teeth,  41 

Carlsbad  Salt,  140 

Casinea  Aculeata,  see  Dogwood 

Castanospermum    Australe,    see 

Black  Bean 
Catarrh,  97 

Duodenal,  8 

of  Stomach,  1,  106 

Catarrhal  Herpes,  32 

■ Sore  Throat,  97 

Caterpillar  Rashes,  64 
Cephalalgia,  115 

Cephalhsematoma  in  Infants,  194 
Cerumen,  181 
Cheese  and  Folliculitis,  37 
Chilblains,  70 

Broken,  76 

Childhood,  diet  in,  221 
"  Chill  on  the  Liver,"  9 


Chloral  in  Insomnia,  113 
Chloretone,  114,  121,  127,  131,  191 

in  Sea-sickness,  146 

Chloride  of  Calcium,  160 
Chocolate  as  a  beverage,  235 
Chromic  Acid  for  Ulcer  of  Mouth, 

35 
Cider  as  a  beverage,  228 
Ciliary  Blephlritis,  176 
Circulatory  System,  148  et  seq. 
Clavus,  121 

Hystericus,  129 

Climacteric  Neuroses,  191 

Climatic  Headache,  142 

Clothing,  209 

Cocoa  as  a  beverage,  235 

Cod  Liver  Oil,  inunction  of,  246 

Codeine,  114 

Coffee  as  a  beverage,  233 

Cognac  as  a  beverage,  229 

Cold    Application    in    Headache, 

120,  141 
Cold  in  the  Chest,  102 

in  the  Head,  97 

Colic  in  Infants,  197 
Collunaria,  99 
Colon,  distension  of,  14 
Condiments,  use  of,  223 
Congestion,  1 
Congestive  Headache,  119 
Conjunctival  Haemorrhage,  176 
Conjunctivitis,  175 

Phlyctenular,  176 

Constipation,  1,  24 

in  Infants,  196 

insufficient  fluid  in,  25,  28 

Convulsions,  25 
Coprsemia,  25 
Corns,  80 

and  weather,  81 

Soft,  82 

Cough,  Dry,  107 

Habitual,  105 

Hysterical,  106 

loud  barking,  106 

Reflex,  181 

Cracked  Fingers,  84 


1']Q 


Index 


Cracked  Lips,  31 
Cramp,  173,  205 
"Crick  in  the  Neck,"  172 
Croton  Oil  Pill,  31 


Deafness,    temporary,    179,    181, 

182 
Debility,  150 
Defeecation,  habit  in,  27 
Defluvium  Capillitii,  49 
Delirium,  113 
Depression,  1 
Diarrhoea,  3 

Infantile,  195,  221 

Diet,  215  et  seq. 
in  Arthritis,  242 

-  -  at  Carlsbad,  243 

—  in  Childhood,  221 

in  Diabetes,  243 

General,  in  health,  200 

in  Gout,  242 

Graduated,  248 

in  Gravel,  242 

Meat,  238 

Milk,  237,  249 

in  Nephritis,  244 

in  Obesity,  239 

in  Old  Age,  222 

Salisbury,  in  Obesity,  240 

Special,  236  et  seq. 

Vegetarian,  236 

Diet-Scales,  216  et  seq. 

Digestibility  Table,  219 

Digestive  System,  1  et  seq. 

Diphtheria,  89 

Diuretin,  135 

Dobell's  Solution,  100 

Dogwood,  rash  from  handling,  66 

Dormiol  as  a  hypnotic,  114 

Drains,  93 

Drinking  Water,  213 

Drowsiness,  9,  115 

Dry  Mouth,  33 

Duodenal  Catarrh,  8 

Dwelling,  the,  212 

Dyes,  irritant,  87 


Dysoxylon  Muelleri,  see  Red  Bean 

Richii,  irritation  from  hand 

Hng,  66 
Dyspepsia,  1,  17 

Atonic,  35 

Dyspeptic  Ulcer,  35 
Dysuria,  189 

Ear,  the,  179  et  aeq. 
Eating  too  Fast,  19 
"Eclipse  Blindness,"  179 
Eczema  of  Lips,  32 

Sun,  67 

Elder  Leaves,  rash  from  handling. 

66 
Emotional  Palpitation,  158 
Enemata  Formulas,  247 

of  Hot  Water,  21 

Nutrient,  246 

Enteroptosis,  45 
Enterospasm,  13,  14 
Enuresis,  188 
Ephelides,  69 
Episcleritis,  176 
Epistaxis,  26,  159 
Eructation,  12 
Erythema  Neonatorum,  194 

Pernio,  70 

Solare,  67 

Eucalyptus   Maculata,   rash  from 

handling,  66 
Exalgin,  118,  131,  133,  134 
Exercise,  30,  200 
Eye,  the,  174  et  seq. 

foreign  bodies  in,  174 

strain,  132 

Fainting,  155 

Falling  Asleep  after  Eating,  2 

Falling  Hair,  49 

Faradic  Current  lor  Chilblains,  7G 

Fatigue  Headache,  141 

Fauchard's  Disease,  37 

Feather-Few,  rash  from,  66 

Fibrositis,  172 

Fig  Poultice  in  Toothache,  42 

Finger  Cracks,  84 


[nd 


ex 


l^i 


"  Fisherman's  Elbow,"  170 
Fissure  of  Anus,  42 
Flatulence,  1,  10,  13 

in  Infants,  197 

Flipping  First  Sound,  149 

Fluid,  daily  amount  necessary,  28 

habitual  quantity,  209 

insufficient,  25,  28 

Flushing  of  Face,  12 
Follicular  Pharyngitis,  96 
Folliculitis,  57 

of  Palate,  37 

Foreign  Bodies  in  Eye,  174 

Formic  Acid,  69 

Formolyptol,  37 

Formulae,  250 

Fortified  Wines,  varieties  of,  228 

Freckles,  69 

Furuncles  of  Ear,  180 

of  Nose,  186 

Gastric  Dilatation,  11,  12 

• Distension,  157,  227 

Function,  16 

Reflex,  47 

Gaultherium  Oil,  93,  102 

Gelsemium,  Gelseminine,  133,  134 

Genito-Urinary  System,  186  et  seq. 

Giddiness,  1 

Gin  as  a  beverage,  230 

Gingivitis,  37 

Glenard's  Disease,  46 

Glycothymoline,  36 

"  Golfer's  Shoulder,"  170 

Gouty  Headache,  142 

Greek  Wines,  228 

"  Growing  Pains,"  172 

Guarana,  128,  236 

Guaranine,  134 

Gumboils,  39 

Gut,  twisting  of,  10 

Habit  in  Defsecation,  27 
Haematoma  Auris,  179 
Hsematuria,  190 
Haemorrhoids,  44 
Hair,  Falling,  49 
Hair  Lotions,  54 


Hamamelis  in  Epistaxis,  160 

Hard  Hats  and  Baldness,  49 

Harvest  Bug,  irritation  from,  58, 
61 

Headache,  Climatic,  142 

from  Fatigue,  141 

in  Fever,  141 

Gouty,  142 

Leeches  in,  120 

in  "  Liver,"  1 

Malarial,  129 

Occasional,  139 

Periodic,  121 

Persistent,  115 

and  Plethora,  118 

in  Renal  Disease,  115 

Toxic,  140 

Heartburn,  12,  15,  209 

Hebra's  Lotion,  for  Cracked  Lips, 
32 

Hedonal,  114 

Hemicrania,  121 

in  Sea-sickness,  143 

Heroine,  114 

Herpes,  Catarrhal,  32 

Preputialis,  33 

Herpetic  Fever,  33 

Hiccough,  16,  17 

Hock  as  a  beverage,  228 

Hop  Pillow,  114 

Hops  in  Insom.nia,  114 

Hordeolum,  56 

Hornet,  sting  of,  59 

Hot  Baths  in  Liver  Chill,  10 

Hot  Water  Drinking,  9 

in  Bilious  Attack,  9,  14 

in  Obesity,  239 

Hyacinth  Bulbs,  rash  from  hand- 
ling, 65 

Hydrogen  Peroxide  for  Hornet 
sting,  60 

Hypertrophic  Rhinitis,  184 

Hypnotics,  114 

Ichthyol,  192 

Pills,  57 

Icterus  Neonatorum,  194 


272 


Index 


India  Pale  Ale  as  a  beverage,  227 
Indigestion,  17 
Infantile  Diarrhcea,  195 

Stomatitis,  194 

Infants,  192  et  seq. 

Influenza  and  Palpitation,  158 

Ingrowing  Toenail,  83 

Insects,  injuries  inflicted  by,  58 

Insomnia,  111 

Fanciful,  114 

Intercostal  Neuralgia,  107 
Intestinal  Croakings,  13 
Invalids  and  Sea-sickness,  147 
Itch  Insect,  irritation  from,  58 

Jigger,  irritation  from,  58 

Kasemol  for  Chilblains,  76 
Kola  as  a  beverage,  235 
Krameria  Lozenge,  92 
Kutnow's  Powder,  140 

Lager  Beer  as  a  beverage,  227 

Languor,  148,  150 

Lapis  DIvinis,  194 

Laxatives,  30 

Lead  Plates  for  Enteroptosis,  46 

Lentigines  of  Crocker,  69 

Lettuce,  preparation  of,  in  In- 
somnia, 114 

Light  Wines,  varieties  of,  228 

Lipoma  Nasi,  183 

"Live  Blood,"  178 

"  Live-Long  Tablets "  in  Heart- 
burn, 15 

"  Liver,"  1 

ChiU  on  the,  9 

Lotio  Sulphuratum,  188 

Low  Arterial  Tension,  148 

Leeches  in  Headache,  120 

Lumbago,  171 

Madeira  as  a  beverage,  228 
Maintenance  of  Individual  Health, 

199  et  seq. 
Malarial  Headache,  129 
Malt  Liquors,  varieties  of,  227 


Marsala  as  a  beverage,  228 

Mastenea,  see  Dysoxylon  Richil 

Mate  as  a  beverage,  236 

Maturation  of  Wine,  229 

Meals,  insufficient  intervals  be- 
tween, 18 

Supernumerary,  208 

Meatus  of  Ear, inflammation  of,  179 

Meibomian  Cyst,  177 

Menstruation,  191 

Menthol  PiU,  14 

Mercury  in  Bilious  Attack,  6 

ia  Headache,  118 

Mesotan  for  Chilblains,  76 

Meteorism,  10 

Migraine,  121 

"  Reflex,"  126 

Migranin,  127,  133 

Milk  Diet,  237 

Skimmed,  in  Obesity,  239 

sterilising  of,  208 

Mlstura  Blsmuthl  Co.,  23 

Morphine  as  a  hypnotic,  113 

in  Sea-sickness,  146 

Moselle  as  a  beverage,  228 

Mosquitoes,  bite  of,  61 

Mountaineering,  Cardiac  failure 
in,  158 

Mouth,  Ulcer  of,  34 

Mower's  Mite,  see  Harvest  Bug 

Muscae  Volitantes,  3,  178 

Muscle  and  Metabolism,  165 

Muscular  Debility,  3 

System,  164  et  seq. 

Myalgia,  108,  170 

Myocardial  Degeneration,  143 

Narcolepsy,  115 

Nares,  congestion  of,  184,  185 

irritation  of,  183 

Nasal  Douche,  99 
Nauheim  System,  164 
Neck,  pimples  on,  57 
Nerve  Stimulants,  233 
Nervous  Dyspepsia,  22 

System,  111  et  seq. 

Nettles,  rash  from  handling,  68 


Index 


273 


Neuralgia,  41,  117,  121,  132 
Neuralgics,  Antl-,  133 
Neurasthenia,  144 
Neuroses,  Climacteric,  191 
Neurosis,  151 
Nose,  the,  182  et  acq. 
Nose-Bleeding,  26,  159 
Numbness,  154,  155 
Nutrient  Enemata,  246 

Obesity,  239 

Occasional  Headaches,  139 

Odol,  36 

Odontalgia,  41 

Odontodol,  42 

CEsophageal  tube  in  tympanites, 

11 
Ophiasis,  52 
Oral  Sepsis,  37 
Otomycosis,  181 
Otorrhoea,  182 
Ozsena,  184 

Palpitation,  157 

Papules,  55,  57,  59 

Paraldehyde,  114 

Paronychia,  77 

Patent  Spirit  as  a  beverage,  229 

Periodic  Headache,  121 

Perry  as  a  beverage.  228 

Pharyngitis,  Follicular,  96 

Phebalium  Argentum,  66 

Phenacetin,  127 

Phenazone,  114,  127,  133,  134 

Phlebitis,  160 

Phlyctenular  Conjunctivitis,  176 

Piles,  2,  44,  45 

Pimples,  on  Buttocks,  57 

on  Neck  and  Face,  55 

Pinna,  deposits  peculiar  to,  179 

"  Pins  and  Needles,"  154 

Plant  Rashes,  64 

Plethora  and  Headache,  118 

Pleurisy,  107,  108 

Pleurodynia,  107 

Poison  ivy,  rash  from  handling,  67 


Poison  Oak,  rash  from  handling,  67 

Sumach,  rash  from  handling, 

67 
Pomades,  55 
Port  as  a  beverage,  128 
Portal  Circulation,  5 

Reservoir,  6 

Vein,  dilatation  of,  5,  9 

Porter  as  a  beverage,  227 
Potassium  Iodide,  142 
in  Headache,  119 


Pot  Still  Whiskey  as  a  beverage,  229 
Pressure  Palsy,  155 
Primula  Obconica,  65 

Sinensis,  65 

Proponal,  114 

Protective  Action  of  Liver,  4 
Psychoses  at  Climacteric,  191 
Purin  Bodies,  134 
Pustular  Eczema,  78 
Pyorrhoea  Alveolaris,  37 
Pyramidon,  133,  134 

Quinine,  133 

Rashes,  from  plants,  etc.,  64  et  aeq. 

Raw  Food,  208 

Red  Aniline  Irritation,  87 

Bean,  poison  from,  66 

Reflex  Migraine,  126 
Refractive  Errors,  126,  128,  132 
Relaxed  Throat,  90 
Renaglandine,  45 
Respiration,  200 
Respiratory  System,  88  et  aeq. 
"  Rest  Cure,"  154 
Restlessness,  113 
Rheumatic  Sore  Throat,  92 
Rhinitis,  Atrophic,  184,  185 

Chronic,   184 

Hypertrophic,   184 

Rhubarb  and  Hsematuria,  190 
Rhus  Diversiioba,  see  Poison  Oak 

Radicans,  see  Poison  Ivy 

Vernix,  see  Poison  Sumach 

Rigg's  Disease,  37 
*'  Run  Down,"  151 

18 


274 


Index 


Salicyl  Acetic  Acid,  135 

Salipyrin,  135 

Salisbury  Treatment,  22 

Salt  and  Albuminuria,  238 

Sandow's  Training  Diet,  216 

Saturday  Night  Paralysis,  155 

Scabies,  58 

Schiedam  as  a  stimulant,  230 

Scurf,  50,  51 

Sea-siclsness,  143 

Sebaceous    Glands,    inflammation 

of,  55 
Seborrhaea,  51 

treatment  of,  53 

♦*  Seeing  Stars,"  178 
Sentinel  Pile,  44 
Septic  Throat,  93 
Serum  Nutrition,  246 

Therapy,  90 

Sherry  as  a  beverage,  228 
Shoulder  Pain,  2 
Skimmed  Milk  in  Obesity,  239 
Skin,  diseases  of,  48  et  aeq. 

Abscess,  198 

Sleep,  201 

after  meals,  203 

Sleeplessness,  134 
Smegma  Bacillus,  186 
Snake  Venom  (ingested),  5 
Soda  Lozenge  in  Heartburn,  15 
Soporifics,  114 
Sore  Throat,  88 

Catarrhal,  97 

Rheumatic,  92 

Spanish  Brandy,  229 
Special  Subjects,  174 
Spiders,  wound  made  by,  58 
Spirits,  229,  232 

Patent,  229 

. Pot  Still,  229 

Spiritus    Saponatus    Ealiaus    in 

Seborrhea,  53,  55 
Spotted  Gum  Rash,  66 
Sprains,  166 
Still  Neck,  171 

Stimulants  in  Bilious  Attack,  7 
Stimulation.  226 


Stinging    Nettle,    irritation    from 

touching,  69 
Stings,  58 

Stitch  in  the  Side,  109 
Stomatitis,  Aphthous,  37 

in  Infants,  193 

Ulcerative,  37 

Stout  as  a  beverage,  227 

Stye,  56,  177 

Sulphonal  as  a  hsrpnotic,  114 

Sun  Eczema,  67 

Sunburn,  67 

Synehisis  SeintlUans,  178 

Syncope,  155 

Synovitis,  168 

Tachycardia,  158 

Taraxacum,  140 

Tartar  on  Teeth,  36,  40 

Tea  as  a  beverage,  234 

Teak,  inflammation  from  sawdust 

of,  67 
Teeth,  Caries  of,  41 

Tartar  on,  36 

Teleangectasis,  182 
"Tennis  Elbow,"  170 
Teno-Synovitls,  168 
Tetronal  as  a  hypnotic,  114 
Theobromine,  133,  134 

Salicylate,  135 

Throat,  Catarrhal  Sore,  97 

Examination  of,  88 

Relaxed,  90 

Rheimaatic  Sore,  93 

Septic,  93 

Sore,  88 

Ulcerated,  93 

Thrombosed  Pile,  45 

Thrush,  194 

Thuya  Occidentalis,  79 

Thyroglandin  in  Obesity,  240 

Tic  Douloureux,  121,  130 

Tinea  Tarsi,  176 

Tobacco,  eSect  on  heart,  157 

and  Insomnia,  157 

Tongue,  Dyspeptic  Ulcer  of,  35 
Ulcer  of,  34 


Index 


275 


Toothache,  41 
■  Tophi  in  Lid,  177 
Toxic  Headache,  140 
Tracheitis,  102 
Trional  as  a  hypnotic,  114 
Trophoneurosis,  53 
Tufnell's  Diet,  218 
Turkish  Baths  in  Liver  Chill,  10 
Tympanites,  10 

Ulcer,  Dyspeptic,  35 

of  Mouth,  34 

of  Tongue,  34 

Ulcerated  Throat,  93 
Ulcerative  Stomatitis,  37 
Uncoolied  Food,  dangers  of,  208 
Urea,  output  of,  222 
Urethane  as  a  hypnotic,  114 
Urticaria,  163 
Uvula,  Elongated,  91 

Variations  in  Blood  Pressure,  154 
Varicocele,  162 
Varicose  Veins,  160 
Variety  of  Occupation,  214 
Vegetarian  Diet,  236 
Veronal  as  a  hypnotic^  114 
Verruca,  78 


Vertigo,  3,  60,  115,  191 
Volvulus  in  Flatulence,  10 
Vomiting  in  Infanta,  195 
Vulvo-Vaginitis,  187 

Warts,  78 

Wasps,  stings  of,  59 

Water  Enemata,  246 

Water,  Hot,  in  Bilious  Attack,  9, 

14 

in  Obesity,  239 

Weakness  due  to  Obscure  Diseases, 

148 

and  low  Blood  Pressure,  150 

Weather  and  Bilious  Attacl^s,  9,  14 

and  Corns,  81 

Weir-Mitchell  System,  154 

in  Enteroptosis,  46 

West  Australian  Blister  Plant,  rash 

from  handling,  66 
Whiskey  as  a  beverage,  229 
Whitlow,  77 

Wine  as  a  stimulemt,  232 
Wines,  maturation  of,  229 
varieties  of,  228 

Xanthelasma,  178 
Xerodermia  Pigmentosa,  69 


Printed  by  Haselt,  Vyai^on  <S'  Viney,  L4-,  London  and  Aylesbury,  England. 


COLUMBIA  UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28(l149)  100M 

RC50 

Wynter 

Minor  medicine 


W99 
1913 


Kc  5"o 


